Hernia

In this condition factsheet:

• The Facts
• Causes
• Symptoms and Complications
• Making the Diagnosis
• Treatment and Prevention

The Facts

A hernia occurs when a portion of tissue in your body bulges into or penetrates a weakened muscle area. Theoretically, hernias can happen anywhere in your body, but most occur in the abdomen between the rib cage and the groin.

There are several types of hernias, some are described below:

• Hiatal hernias (also known as diaphragmatic or hiatus hernias) occur when a piece of your stomach protrudes through the diaphragm (the muscle that separates the chest region from the abdominal area) via the opening through which the esophagus (food tube) passes into the stomach. Hernias may also occur in infancy because of a weakness in the abdominal wall. They occur more frequently in premature babies. In Canada, around 1,200 cases of hiatal hernias were reported between 2006 and 2020. There are 2 main categories of hiatal hernias:
• Sliding hiatal hernias are more common, where a part of the esophagus connected to the stomach slides out, above the diaphragm. These types of hernias do not usually cause symptoms, though they may cause a sensation of burning, gassiness, or fullness in the stomach.
• Paraesophageal hiatal hernias are less common, but can be life-threatening, as larger parts of the stomach (and in severe cases, parts of the intestines too) slide and bulge out above the diaphragm. If the bulge becomes trapped or pinched by the diaphragm, it can cause a problem called strangulation. This usually results in symptoms such as excessive bloating, burping, chest or abdominal pain, or difficulty swallowing. If you notice that these symptoms are persistent, contact your doctor or emergency medical services immediately. Strangulated paraesophageal hernias can be life-threatening if left untreated.
• Inguinal or groin hernias occur when part of the abdominal contents (usually part of the intestine or a piece of bowel) protrudes into the groin area. This is the most common type, accounting for around 75% of all hernias. Men are 9 times as likely as women to get them. They most often occur in children under the age of 5, and people over the age of 70 (on one side of the groin or both). The hernia operation is one of the most common surgery procedures. Umbilical hernias are similar to inguinal hernias but are found in the area of the umbilicus (the navel or belly button area). This occurs most commonly in infants and children. The belly button may bulge outwards, especially when they are crying.
• Incisional hernias occur when a piece of intestine protrudes through a weakness in the abdominal wall in an area where surgery has been performed.
• Femoral hernias occur when a piece of intestine protrudes though the passage that is normally used by large blood vessels as they pass between the abdomen and leg.

Causes

The cause of some hernias cannot be pinpointed, but many result from increased pressure within the abdomen, a weak spot in the abdominal wall, or a combination of the two. The weakened abdominal wall may be present as a birth defect or develop over time from injury or surgery. Age also plays a factor as hernias are more likely to develop over the age of 50. Genetic abnormalities may play a role, especially for hernias occurring in newborns.

In adults, hiatus hernias commonly develop in pregnant women and overweight people due to the increased pressure on the abdominal wall. Other stressors may include constipation (straining while having a bowel movement), lifting heavy weights, or prolonged coughing or sneezing.

In men, an inguinal hernia will commonly develop in the groin, specifically in a region called the inguinal canal. This is where the spermatic cord and blood vessels to the testicles pass out of the abdominal cavity and into the scrotum. A weakness in the abdominal tissues at this point can allow a loop of bowel to pass out of the abdomen by following the path of the spermatic cord (indirect inguinal hernia) or between the opening into the inguinal canal and the pubic bone (direct inguinal hernia).

In women, inguinal hernias are rare, but can develop where the tissue that binds the uterus exits from the abdomen and joins with the tissue surrounding the vaginal opening.

Umbilical hernias may be present at birth. In adults, they may develop when there is a weakness in the tissue in the umbilical area combined with increased pressure on the abdominal wall.

Symptoms and Complications

If you have a hiatal hernia, you usually don't have any symptoms unless the sphincter muscles around the lower end of the esophagus become weak. When this occurs, the valve between the stomach and esophagus (gullet) won't stay closed, and stomach acids will spill into the esophagus. As a result, you may experience heartburn, sharp pain, regurgitation, belching, and sometimes bleeding. At night, you may experience coughing, breathlessness, or a choking sensation.

Signs and symptoms of an inguinal (groin) hernia include discomfort while bending over or during lifting. You may feel a small egg-like lump in your groin that may become more prominent with certain activities such as coughing. It will usually disappear when you lie down. Coughing or straining may make it uncomfortable or painful. If the bulge persists and is accompanied by nausea and vomiting or abdominal pain, this can be a sign that the hernia has become obstructed or strangulated.

Although rare, an untreated hernia that strangulates may result in gangrene (death of tissue), which is a life-threatening condition and requires emergency surgical attention. Symptoms of strangulation include pain, swelling, discoloured bluish or red skin, vomiting, and an inability to urinate.

Children with strangulated inguinal hernias may have fever and vomiting and should be seen immediately by a doctor.

Inguinal hernias may not make themselves known until your abdominal wall is weakened after years of straining during bowel movements or from heavy coughing or lifting. Smokers are prone to such hernias. Physical exertion such as lifting may exacerbate a hernia by suddenly causing the weakened abdominal lining to give way.

Paraesophageal hernias usually have no symptoms, but if symptoms do occur, the most common are pain, indigestion, nausea, and retching.

Making the Diagnosis

A hiatal hernia may be diagnosed using X-rays and diagnostic tests such as endoscopy (looking at the stomach via a fiberoptic tube), esophageal manometry (using a special instrument to measure your sphincter pressure), and tests to measure your esophageal acidity.

It is important to get regular check-ups during pregnancy. Doctors can diagnose hiatal hernias before delivery using an ultrasound, which can help find abnormalities in the diaphragm and lungs.

During a routine physical examination your doctor may discover an inguinal hernia. Your doctor will usually diagnose it by feeling the area of the internal inguinal ring, deep in the groin. If there's a bulge in the area, then there's a good possibility that it's due to a hernia and imaging studies are not required.

Treatment and Prevention

General hernia prevention strategies include avoiding activities that cause abdominal strain (e.g., lifting heavy weights), and if you're overweight, losing weight.

In most hiatal hernia cases, treatment consists of relieving the accompanying heartburn with medication and modifying the diet. Losing weight is also recommended as a way to help relieve pressure. If you experience discomfort at night, it may help to sleep with the upper part of your body propped up on pillows or with the head of your bed raised. It is important not to eat for several hours before lying down, so that the stomach has time to empty. Standing straight rather than slouching is also a good idea. Surgery is uncommon and is reserved as a last resort for severe cases if medical and dietary management hasn't helped. To treat hiatal hernia in newborns, surgery is necessary to repair the diaphragm after the baby is born.

If you have an inguinal or umbilical hernia, it is generally repaired by surgery that places the protruding mass back where it belongs and reinforces the weakened area by sewing the muscles together. This is a simple operation that is sometimes performed under local anesthetic.

It's important to go for regular medical follow-up after surgery because of possible complications. Some surgeons recommend restricting exercise; however, most will encourage a speedy return to activities. Hospital stays of 2 or 3 days for surgery have been reduced in the last few years to a same-day discharge.

Laparoscopic hernia repair is done through a tiny incision and avoids the need for invasive open surgery. A television screen enables the surgeon to clearly see inside the person's body. Studies have shown that this method of treatment promotes faster healing with less likelihood of recurrence.

Wearing a truss is no longer recommended for treatment of hernias. In fact, it can even make your hernia worse by weakening tissues.

Paraesophageal hernias are generally treated with surgery.

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