An epigastric hernia is a common type of abdominal wall hernia that occurs in the midline of the upper abdomen. This condition involves a protrusion of tissue, typically fat or sometimes a portion of the intestine, through a weakness or defect in the linea alba, which is the fibrous band of connective tissue running vertically between the breastbone and the belly button. The defect allows the contents of the abdomen to push outward. Although many small hernias are asymptomatic, a medical diagnosis is necessary because of the potential for complications.
Recognizing the Patient’s Symptoms
A patient’s description of their symptoms often serves as the first indication of an epigastric hernia. The most common sign is localized pain or discomfort in the upper middle abdomen, the area known as the epigastrium. This discomfort is often described as a dull ache or a burning sensation that worsens with activities that increase intra-abdominal pressure, such as lifting, coughing, or straining.
The objective sign is a palpable lump or bulge situated between the sternum and the navel. This swelling may be intermittent, only becoming noticeable when the patient is standing or actively straining. The characteristic disappearance, or reducibility, when they lie down is a significant clue. Associated symptoms can include tenderness around the bulge, and in some cases, nausea or bloating may be present, especially if the hernia is larger.
The Clinical Examination and Assessment
Diagnosis typically begins with a thorough clinical examination and a comprehensive patient history. The physician inquires about the onset, duration, and aggravating factors related to the symptoms. They will ask about activities that make the bulge appear or the pain intensify, as well as any history of chronic coughing, heavy lifting, or prior abdominal surgeries.
The physical examination involves inspection and careful palpation of the epigastric region while the patient is in various positions. The physician visually checks for a bulge when the patient is standing and uses their fingers to feel for a fascial defect in the linea alba. A fundamental technique is the Valsalva maneuver, where the patient is asked to bear down or cough. This increases abdominal pressure, forcing contents through the defect and making the bulge easier to feel. The physician assesses the lump’s reducibility by gently attempting to push the protruding tissue back into the abdominal cavity. This manual assessment helps distinguish the hernia from other subcutaneous masses like a lipoma or a rectus diastasis.
The Role of Medical Imaging
While clinical assessment is often sufficient for a confident diagnosis, medical imaging is utilized when the diagnosis remains unclear, the patient is obese, or when complications are suspected. Ultrasound is frequently the initial imaging modality of choice due to its non-invasive nature, accessibility, and ability to provide real-time visualization. During an ultrasound, the patient may perform the Valsalva maneuver, which helps confirm the presence of a defect and visualize the tissue protruding through the abdominal wall.
Ultrasound allows the doctor to confirm the contents of the hernia sac, which is most often preperitoneal fat, but can sometimes include omentum or bowel. It is also effective for measuring the exact size of the fascial defect and assessing for signs of incarceration, a serious condition where the herniated tissue is trapped and cannot be reduced.
Computed Tomography (CT) Scans
CT scans are generally reserved for more complex diagnostic situations, such as when the hernia is difficult to locate on a physical exam. They are also used if there is a suspicion of bowel obstruction or strangulation, which involves a compromised blood supply to the tissue. The detailed cross-sectional images provided by a CT scan are useful for surgical planning in larger or recurrent cases.