Hernia

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Hernia

Overview

Hernia is the protrusion of a muscle or tissue through the weakened wall of a cavity (eg: abdomen or pelvic floor) from its original site. Usually, hernia appears as a bulge arising from the cavity. It can occur in many areas of the body. The most common areas where hernias are observed are the abdomen and pelvic floor, groin, upper thighs and umbilicus (belly button area).

Abdominal and inguinal hernias are the most common. Men suffer from inguinal hernias more often than women.

Causes

The causes of a hernia are different for different types. Each of the specific types of a hernia may have a specific cause.

Inguinal Hernia

In most cases of inguinal hernia, weakening of the abdominal wall is the primary cause. At birth, when the abdominal lining fails to close properly, it results in inguinal hernia. Later on, this type of hernia results from weakened muscles due to ageing, strenuous physical activity and repeated coughing. Abdominal weakness that leads to a hernia could also be a result of an injury or an abdominal surgery.

Coughing and straining increase the pressure within the abdomen and causes the intestinal organs to protrude through the weak abdominal wall.

Causes of an inguinal hernia include:

  • Increased physical activity
  • Pregnancy
  • Chronic cough and cold
  • The pre-existing weak spot in the abdominal wall
  • Straining during bowel movement and urination

Femoral Hernia

Though the actual cause of a femoral hernia is not yet known, it could arise as a result of the weakening of the femoral canal. The femoral canal is a tube-like structure in the front portion of the thigh and contains lymph nodes and connective tissue. It is weakened due to several reasons. –

  • Chronic constipation
  • Lifting heavy weights
  • Overweight
  • Chronic cough
  • Childbirth
  • Difficult urination

Obturator Hernia

Natural ageing process could be one of the major causes of an obturator hernia. As the ageing process results in loosening of the muscle mass and fatty tissue, intestine and abdominal contents can pass from the pelvis to the thigh through the obturator canal. Women are more likely to develop an obturator hernia when compared to men. Among women, those who have given birth multiple times are more vulnerable.  Some other causes of an obturator hernia include loss of muscle tissue, sudden weight loss, and malnutrition.

Umbilical Hernia

  • Umbilical hernia occurs when the abdominal contents protrude through the belly button. This happens when the abdominal muscles fail to close completely at the umbilicus.
  • This type of hernia is most common in babies but can rarely occur in adults as well. Babies who are born premature or low birth-weight are vulnerable to this type of hernia.
  • In adults, umbilical hernia could be caused by the sudden pressure on the weak part of the abdominal muscle. Causes of this hernia in adults include:
  • Overweight
  • Frequent pregnancies
  • Excess abdominal fluid
  • Abdominal surgery
  • Chronic cough
  • Multiple pregnancies (twins, triplets, etc.)

Hiatal Hernia

Hiatal hernia diseases occurs due to injuries or damages that weaken muscles tissues. Increase pressure on the muscles around the stomach leads to pushing of the stomach through the diaphragm. The factors that cause such extreme pressure include:

  • Coughing
  • Vomiting
  • Lifting heavy weights
  • Straining during bowel movements
  • In some cases, people are born with a large hiatus that allows the stomach to move through it easily.

Apart from the causes of individual types of hernia, some general causes also play a role in causing or triggering hernia. An increase in the intra-cavitary pressure could result in hernia. The major causes of increase in pressure in the abdomen include:

  • Excessive involvement in heavy weight-lifting.
  • Injuries that cause sharp blows to the abdomen
  • Diseases of the lungs that cause repeated coughing
  • Failure of proper closure of the abdominal wall in the baby during its growth in the womb
  • Excessive straining during urination and constipation
  • Diseases of the stomach and other organs like enlarged prostate and bladder cancers
  • Ascites (fluid in the abdominal cavity)
  • Persistent Vomiting
  • Smoking
  • Significant Weight gain
  • Pregnancy
  • Incorrect Posture
  • Surgery

Symptoms

Patients with Hernias may be symptomatic or asymptomatic. Symptoms of a hernia are related to its size, location, and presence of complications.

In patients who are asymptomatic, the patients are diagnosed during a routine medical or physical examination for an irrelevant or unrelated symptom or problem.

Each type of hernia may be characterized by a varied set of symptoms, apart from the general symptoms. Some symptoms of a hernia based of their type are as follows:

Inguinal Hernia

  • Common signs and symptoms that indicate an inguinal hernia include –
  • Bulge on either side of the pubic bone
  • Pain or discomfort in the groin
  • Heaviness in the groin
  • Weakness in the groin
  • Pain and swelling around testicles

Femoral Hernia

In the case of femoral hernia, most of the small-sized hernias go unnoticed. Only the large hernias could be noticeable and can cause discomfort. There could be a bulge in the groin area, near the upper thigh. The bulge might appear and become worse when standing up, lifting heavy weights or being subject to a strain of any other kind. Hip pain could be a major symptom for a femoral hernia as these hernias are located very close to the hip bone.

In severe cases, femoral hernia could lead to the obstruction of intestines and put an individual’s life in danger. Symptoms that indicate strangulation or obstruction of intestines include:

  • Intense stomach pain
  • Sudden pain in the groin
  • Nausea
  • Vomiting

This hernia could interfere with the blood flow to the intestines. Hence emergency treatment is required. If delayed, the condition may become fatal.

Obturator Hernia

A bowel obstruction is a major symptom that indicates an obturator hernia. In some cases, bowel obstruction presents before a hernia is identified.

Understanding the symptoms of bowel obstruction helps one to identify an obturator hernia. Some symptoms of bowel obstruction during a hernia include:

  • Abdominal bloating
  • Pain
  • Constipation
  • Nausea
  • Vomiting
  • Pain in the middle of the thigh, which is otherwise termed as Howship-Romberg sign, is a symptom related to this type of hernia.

Umbilical Hernia

In babies, umbilical hernias can be seen when they are crying, laughing or straining while pooping. In a relaxed posture, this hernia is not visible. Common symptoms of umbilical hernia in children include:

  • Bulge near the umbilical area
  • Pain
  • Sudden vomiting
  • In adults, the symptoms for an umbilical hernia include:
  • Bulge near the navel area
  • Severe pain and discomfort

Hiatal Hernia

Large hiatal hernias show symptoms but smaller ones have no signs or symptoms. Some symptoms of the larger hiatal hernias include:

  • Acid reflux
  • Heartburn
  • Regurgitation of food or liquids into the mouth
  • Difficulty in swallowing
  • Abdominal pain
  • Discomfort in the chest
  • Shortness of breath
  • Vomiting of blood
  • Black-colored stools

These hernias could cause gastrointestinal bleeding, which would further result in vomiting of blood and black stools.

Risk factors

Hernia can occur to anyone but certain individuals are more vulnerable to it than the general population. Factors that put individuals at a higher risk for hernia include:

  • Gender – Compared to women, men are 8 times more likely to develop hernia, especially inguinal hernia.
  • Age – Though hernia is common in children as well in adults, the older people are more vulnerable to it as the muscles weaken with age.
  • Race – White Americans are more vulnerable to hernia than those of other races.
  • Family History – If there was a close relative who had hernia, it is likely to pass on to others in the family.
  • Smoking – Cough that arises from smoking could result in hernia.
  • Constipation – Being constipated results in straining during bowel movements.
  • Premature Birth – Premature birth and low birth weight could lead to the baby having hernia later.
  • Previous Hernia Repair – A person, who has undergone treatment for hernia, is at a higher risk of having it again.
  • Risk factors for hernia include diseases and conditions that can weaken muscles or cause increased pressure within the body cavities. Examples of conditions that lead to muscle weakening include:
  • COPD (Chronic obstructive pulmonary disease)
  • Pregnancy
  • Collagen vascular disease
  • Peritoneal dialysis
  • Previous open abdominal surgery for appendix
  • Obesity
  • Smoking

Diagnosis

Most hernias like inguinal or incisional hernias are diagnosed when the doctor conducts a physical examination. Sometimes hernias are visible when you stand upright or can be felt when the patient bears down.  The doctor may ask the patient to strain or cough and feel for the swelling in the groin or abdomen.

The doctor examines a patient with inguinal hernia in the standing position. The doctor will look for a cough impulse.  The patient is asked to cough and the sac can can be felt or observed. Proper abdominal and pelvic examination of the patient is done depending on the site of the sac.

  • Abdominal X-rays: These are used if an obstruction of the bowel is suspected.
  • Herniogram: This is a special x-ray that helps diagnose the presence of hernia. This test is not commonly used as it involves an injection with a needle. In this x-ray, the radio-opaque liquid used in x-rays is injected into the abdominal cavity of the individual who is suspected of having hernia. If there is a hole in the abdominal wall, the injected liquid trickles through the hole. This can be visible on the x-ray. In cases of individuals who have a history of hernia in their life, this could be helpful to identify the recurrence.
  • Ultrasound scan: An abdominal ultrasound may preferable in femoral hernia and umbilical hernias. The ultrasound scan done to diagnose a hernia is similar to that of the scan used on pregnant women to understand the wellbeing of the fetus. An ultrasound scan gives a shadowy, black and white picture. The results of an ultrasound scan are dependent on the operator. A skilled operator could get a detailed scan report. The sensitivity of an ultrasound scan in the detection of hernias in the groin is said to be greater than 90% while specificity is between 82 – 86%.
  • Endoscopy: A small camera attached to a tube is passed down into your throat, esophagus and stomach to observe the internal structures of the digestive tract. This is useful in the case of a hiatus hernia. The images of hernia present inside the body can be obtained using endoscopy.
  • Barium enema: A series of X-ray pictures of your digestive tract in the abdomen are taken and recorded after drinking a solution of barium. This helps to see the intestinal tract.
  • CT Scan and MRI: The CT scan uses x-rays and forms continuous images of the cross section of the area scanned. An MRI scan is a modern test that has proven to be very effective in diagnosis. This test uses a strong magnetic field for diagnosis. These are used in diaphragmatic hernias and other non-palpable or unsuspected hernias. Details of the abdominal wall, anatomical site of the hernia sac, the contents present in the sac, and other related complications such as obstruction and strangulation can be identified with the help of these scans. Usage of these scans is very effective in identifying athletic pubalgia or sports hernias which could occur at any age.

Treatment

The aim of a hernia repair is to reposition the herniated bowel and strengthen the weak muscles of the abdominal wall

Umbilical hernias in children below 4 years of age usually heal by themselves.

Treatment of hiatus hernia requires lifestyle changes such as weight loss, and good eating habits. Symptomatic treatment includes medicines that reduce acid secretion. In severe cases, laparoscopic fundoplication may be done

For hernias that are small and without discomfort, doctors recommend waiting. In children, the doctors might apply manual pressure to reduce the bulge prior to considering surgical treatment.

Treatment is mandatory for laparoscopic hernia surgeries that are large and painful.

Various types of treatments for hernia include

  • Medication
  • Surgery
  • Lifestyle changes

Medication: Medications are required for hiatal hernia. OTC drugs and prescription medications are ordered to relieve symptoms of a hiatal hernia. Medicines like antacids, H2 receptor blockers, and proton pump inhibitors are commonly prescribed for the treatment.

Surgery: Surgery is a key option in most cases to relieve discomfort and prevent serious complications.

Surgeries that are performed to treat a hernia are of two major types:

  • Open hernia repair
  • Laparoscopic repair

Open Hernia Repair

In open hernia repair, the surgeon makes an incision or a cut in the groin and pushes the protruding tissue back into the abdomen. This is done after application or administration of local or general anesthesia. Following this, a synthetic mesh is reinforced after the surgeon sews the weakened area. This is also called as hernioplasty. The opening is then closed with stitches or surgical glue. A person who underwent open hernia repair would take several weeks to resume normal activities.

Laparoscopic Repair

In laparoscopic repair, a surgeon operates through several small key-hole cuts in the abdomen. Gas is used to inflate the abdomen for a clear view of the internal organs. A laparoscope or a small tube which contains a tiny camera on one end is inserted through one of the cuts. The internal organs are seen through the camera on a screen. The surgeon uses the other cuts to repair a hernia identified in the body.

The patients who undergo a laparoscopic repair experience far less discomfort compared to those who have undergone open surgery. The scars are also very minimal or small. These patients can resume normal activities sooner.

This procedure was found effective for people who have had hernias recur after traditional hernia surgery. It was also seen to be a good choice for those with hernias on both sides of the body.

This procedure is said to have minimum complications when performed by an experienced professional.

Successful treatment of hernia through surgeries depends on certain factors like:

  • Surgeon’s expertise
  • Size of a hernia
  • Anticipated recovery time
  • Cost of treatment

Lifestyle changes: Changes in lifestyle will not make a hernia go away but it can play an effective role in keeping the body weight in a controlled range. Body weight is the major trigger factor for a hernia. Dietary alterations, exercise, giving up smoking can improve symptoms to a large extent. Avoiding certain foods like spices and heavy meals can prevent one from experiencing acid reflux and heartburn.

Prevention

Hernia is caused due to muscle weakness, which cannot be prevented always. Certain activities that cause increased strain on the body can be avoided in order to prevent hernias and also avoid triggering hernias already present. Some tips that help in such prevention include:

  • Treating common cough before it gets worse – Persistent cough could make a hernia worse. Therefore it is important to treat a cough in its early stages before it causes the hernia.
  • Maintaining a healthy body weight – Being overweight increases the abdominal pressure. This increases the risk of developing an inguinal hernia. Diet and exercise can be used to maintain a healthy weight.
  • Avoiding strenuous physical activity – a sudden increase in the physical activity can trigger a hernia and therefore it has to be avoided.
  • Avoiding rapid weight loss – Weight loss diets that lack proteins could lead to hernia. This is because diets that lack essential protein could weaken the muscles of the abdomen. A weakened muscle is a cause for a hernia.
  • Using good body mechanics – bending at the knee instead of the back while lifting weights will reduce the effect on the abdomen.
  • Avoiding heavy weights – lifting weights that strain the body can result in increased pressure on the abdomen.
  • Avoid smoking – Smoking cause chronic cough, which triggers hernia. Avoiding smoking decreases the risk of a hernia.
  • Treat constipation – Any strain during bowel movements or urination is to be avoided as it results in increased pressure in the abdomen, which could further lead to hernia.

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