Unexplained Stomach Pains? It Could be a Hernia.
Abdominal pain is one of the more common reasons for patients to see their doctors. Unfortunately, a diagnosis is, many times, not so obvious. Despite gathering all the details of a patient’s story and performing a thorough exam, I am often left explaining that the abdomen is rather like a “black box” which sends various signals that are difficult to interpret. One consideration of ambiguous belly pain that is often overlooked is a hernia. While some hernias are obvious, some are quite subtle and difficult to diagnose. This blog will cover the different hernias which can occur in the abdomen.
What IS a Hernia?
A hernia is a protrusion of part of an organ through the wall of the cavity containing it. Here, we'll keep discussion purely to abdominal hernias though herniations can occur elsewhere in the body such as a herniated disc in the spine.
Within the abdominal cavity, intestines and finger-like projections of fatty tissue fill most of the space. These organs and tissue can get pushed through the wall of the abdomen at various weak points. Hernias can come slowly with consistent pressure weakening the supportive tissues or they can come suddenly given enough pressure.
- Pain: Hernias are often painful, but sometime the pain is vague and difficult to pinpoint.
- Made Worse With Abdominal Muscle Strain: Pain is made worse with straining and increasing pressure in the abdomen. This can occur with straining due to lifting, toileting, coughing or sneezing.
- A Soft Lump in the Abdomen: A bulge may or may not be felt depending on the location of the hernia and it may or may not disappear with pressure to it.
- Difficulty with Bowel Movements: Sometimes if the hernia involves the bowels, changes in bowel habits are noted such as constipation or pain with bowel movements.
Types of Abdominal Hernias
Inguinal Hernia: These hernias are the most common, occurring in the groin or the crease at the junction of the abdomen and leg. They can occur in men, women and children but are more common in men. They can run in families and occur on one side or both. If one-sided, the hernia is found on the right side 75% of the time. These hernias are divided into two types, indirect and direct based on their location within the same general area. Indirect hernias occur along the pathway made by the testicles during development in the womb. The testicles start in the abdomen and then migrate into the scrotum. Following this process, the tissues come back together, much like a ziplock bag. If the tissue does not come together properly or enough pressure is applied, herniation can occur. Direct hernias occur in the same area at the base of the abdomen where the muscles have a tendency to weaken making herniation more likely. Both types of inguinal hernia increase in frequency with age.
Femoral Hernia: Openings in the abdomen exist a bundle of arteries, veins and nerves pass into the legs. If a defect exists at this opening or stretches significantly, bowel can push through, causing a hernia bulge just below the crease of the abdomen/leg. This hernia occurs mostly in women, likely due to the dynamic changes that the pelvis makes with childbearing.
Incisional Hernia: In a surgery that occurs in the abdominal cavity, the surgeon carefully opens up the skin, the fatty tissue layer, the muscle and finally the tough inner barrier called the fascia. When the job is done in the abdomen, the layers are stitched back up, fascia, muscle, fatty tissue and finally skin. This tissue usually heals and comes together, but it is usually not quite as strong as before. This leaves a point of weakness for a hernia to occur, but may not occur for even years after the surgery. Fatty tissue and/or bowel can emerge through the fascia layer or due to a stretching in the fascia and cause a bulge at the incision. Sometimes the pain is not directly below the scar on the skin because the layers can shift from the original pathway into the abdomen. In general, the bigger the incision, the bigger the risk.
Umbilical Hernia: The umbilicus (belly button) is the remnant of the umbilical cord, the lifeline of development, no longer needed after birth. Though things seal off after the cord withers in the first two weeks of life, a defect can exist. Sometimes children are born with a herniation. Sometimes a hernia emerges later in life. Pregnancy, weakening of the abdominal muscles and increasing abdominal contents due to obesity can increase the risk of an umbilical hernia.
Epigastric Hernia: This hernia occurs in the midline of the abdomen, like the umbilical hernia. The epigastric hernia occurs between the belly button and the lower line of the rib cage. A lack of muscle along the midline of the abdomen along with a defect in the fascia make this hernia possible. It most often occurs in adult men and involves fatty tissue (rarely bowel) entering the hernia defect.
Spigelian Hernia: This hernia occurs at the outer edge of the rectus muscle (six pack). Though this hernia is relatively rare, it is ambiguous and difficult to diagnose. Like umbilical hernias, weakening of the abdominal muscles or stretching with pregnancy or obesity can increase risk for this hernia.
Obturator Hernia: This hernia is very rare and equally ambiguous. It happens mostly in women, occurring when the abdomen protrudes low and deep in the cavity through the opening in the pelvis bone called the obturator foramen. It is very deep and no bulge is felt. The depth also makes for vague pain symptoms and difficulty making the diagnosis.
Hiatal Hernia: This common hernia is different from the other hernias discussed. It is technically an abdominal hernia, however, and bears consideration. A hiatal hernia occurs at the junction of the stomach, diaphragm muscle and esophagus. Weakening in the diaphragm muscle causes the normal anatomy to be distorted and the stomach to pull up via the esophagus into the chest. The stomach can also bulge up through another location in the diaphragm away from the esophagus junction. Regardless of where the bulging occurs, the symptoms are similar with acid reflux and heartburn.
Aside from the pain caused by hernias, one feared risk can occur—strangulation. Strangulation of a hernia occurs when bowel and fatty tissue emerge into the hernia sac and become trapped, unable to be pushed through. If bowel is present in the hernia it can lose its blood supply and die. Strangulation is an emergency and surgery must occur within six hours in general to save the bowel. While, uncommon, this complication is serious. Inguinal hernias strangulate on the order of around 1% per year. For this reason, it is very important you seek medical attention if you suspect a hernia.
Most often the diagnosis of a hernia is clinical based on history and exam. Occasionally, however, ambiguous symptoms and a lack of findings require an ultrasound or CAT scan to be performed to improve the chances of making the diagnosis.
In general, hernias are treated surgically. The defect is brought back together, keeping the contents in the secure in the abdomen. Often, the surgery is done with a scope, keeping the incision quite small. Occasionally, mesh is needed to enhance the repair of the defect. For the most part, hernia surgeries are outpatient meaning that an overnight hospital stay is not required. Treatment for hiatal hernias is aimed at reducing acid production by the stomach and surgery is rarely required.
Abdominal hernias are common. Usually they are obvious with a bulge that is tender and worsened by increasing pressure in the abdomen. Occasionally, however, the symptoms can be ambiguous and a bulge is not obvious. Because of this, with abdominal pain that does not have a ready diagnosis, hernia should be a consideration. If you have a hernia or such ambiguous symptoms, see your doctor. Even obvious hernias should be examined due to the potential risk of strangulation.
Live, and live well!