Epigastric Hernia: Symptoms, Diagnosis, and Treatment

An epigastric hernia is when a lump forms between the belly button and breastbone where a weakness in the abdominal muscle allows the tissues of the abdomen to protrude through the muscle.

Epigastric hernias can be congenital (present at birth) or acquired. They are similar to an umbilical hernia, except the umbilical hernia forms around the belly button and the epigastric hernia is usually between the belly button and the chest.

An epigastric hernia is typically small enough that the peritoneum, or the lining of the abdominal cavity, as well as intra-abdominal fat, pushes through the muscle wall.

In minor cases, the issue may be diagnosed during a CT scan or other testing for an entirely different issue, and may never cause symptoms. In fact, many epigastric hernias are diagnosed in adults, rather than in children. In severe cases, portions of an organ may move through the hole in the muscle.

Risk Factors of Epigastric Hernias

Risk factors for epigastric hernias include:

• Diabetes
  
• Smoking
• Lifting heavy weights or objects
• Strenuous activities
• Being overweight
• Steroid use
• A previous pregnancy
  

These conditions and activities weaken abdominal muscles and stretch the abdominal wall, which can cause epigastric hernias.

Epigastric Hernia Symptoms

Epigastric hernias may seem to appear and disappear, which is referred to as a reducible hernia. The hernia may not be noticeable unless the patient is crying, pushing to have a bowel movement, or another activity that creates abdominal pressure.

The visibility of a hernia makes it easily diagnosable, often requiring no testing outside of a physical examination by a physician.

Treatment in Children

An epigastric hernia will not heal by itself and does require surgery to be repaired. However, unless the hernia threatens to become an emergency, surgery can be postponed until the child is older. Toddlers tend to tolerate surgery better than newborns, so it may be beneficial to wait before surgery is performed.

Treatment in Adults

It is not uncommon for an adult to be diagnosed with an epigastric hernia that they were unaware of earlier in life. It is also possible for a hernia that was known to be present for many years to become an issue as the individual ages.

For many, a hernia does not cause symptoms until later in life due to obesity, muscle weakness, or strain on the muscular wall of the abdomen. In these cases, surgical repair may be necessary if the hernia is causing pain or threatens to become strangulated.

When an Epigastric Hernia Is an Emergency

A hernia that gets stuck in the out position (incarcerated hernia) is considered an emergency.

An incarcerated hernia can become a strangulated hernia, where the tissue that bulges outside of the muscle is being starved of its blood supply. This can cause the death of the tissue that is bulging through the hernia.

Either of these require immediate medical attention.

Surgery

Epigastric hernia surgery is typically performed using general anesthesia and can be done on an inpatient or outpatient basis. If the patient is a child, special care should be taken to adequately prepare children for the surgery.

This surgery is performed by a general surgeon. If the patient is a child, a surgeon who specializes in pediatrics is typically performs the procedure.

Once anesthesia is given, surgery begins with an incision on either side of the hernia. A hernia can be repaired via an incision below the hernia, or laparoscopically/robotically with small incisions.

The surgeon then isolates the portion of the abdominal lining that is pushing through the muscle. This tissue is called the hernia sac. The surgeon returns the hernia sac to its proper position, then begins to repair the muscle defect.

If the defect in the muscle is small, it may be sutured closed. The sutures will remain in place permanently, preventing the hernia from returning.

For large defects, the surgeon may feel that suturing is not adequate. In this case, a mesh graft will be used to cover the hole. The mesh is permanent and prevents the hernia from returning, even though the defect remains open.

If the suture method is used with larger muscle defects (approximately the size of a quarter or larger), the chance of reccurrence is increased. The use of mesh in larger hernias is the standard of treatment, but it may not be appropriate if the patient has a history of rejecting surgical implants or a condition that prevents the use of mesh.

Once the mesh is in place or the muscle has been sewn, the laparoscope is removed and the incision can be closed. The incision can be closed in one of several ways. It can be closed with sutures that are removed at a follow-up visit with the surgeon, a special form of glue that is used to hold the incision closed without sutures, or small sticky bandages called steri-strips.

Recovery

Most hernia patients are able to return to their normal activity within six weeks. Older patients may take longer to recover.

The abdomen will be tender, especially for the first week. During this time, the incision should be protected during activity that increases abdominal pressure by applying firm but gentle pressure on the incision line.

Protect the incision during activities such as:

• Moving from a lying position to a seated position, or from a seated position to standing
• Sneezing
• Coughing
• Crying, especially if the child turns red in the face from the effort
• Bearing down during a bowel movement
• Vomiting