Hernia

Original Editor - Lucinda Hampton Top Contributors - Lucinda hampton, Kim Jackson and Claire Knott  

Introduction

A Inguinal Hernia.png

A hernia occurs when there is a weakness or hole in the peritoneum, the muscular wall that usually keeps abdominal organs in place.

This defect in the peritoneum allows organs and tissues to push through, or herniate, producing a bulge.

The lump may disappear when the person lies down, and sometimes it can be pushed back into. Coughing may make it reappear[1].

The most common types of hernia are[2]:

  • Inguinal (inner groin) see R image
  • Incisional (resulting from an incision)
  • Femoral (outer groin)
  • Hernia umilicalis.jpg
    Umbilical (belly button) see image R second down.
  • Hiatal (upper stomach).

Causes

All hernias are caused by a combination of pressure and an opening/weakness of muscle or fascia; the pressure pushes an organ or tissue through the opening or weak spot. Sometimes the muscle weakness is present at birth; more often, it occurs later in life.

Anything that causes an increase in pressure in the abdomen can cause a hernia, including:

  • Lifting heavy objects without stabilizing the abdominal muscles
  • Diarrhea or constipation
  • Family History—Although family history may not guarantee a hernia, research shows it is a reliable predictor of one occurring.
  • Persistent coughing or sneezing
  • Obesity, poor nutrition, and smoking (all weaken muscles and make hernias more likely).
  • Pregnancy—The risk is small, but studies show that pregnancy is associated with an increase in the risk of hernia recurrence.
  • Injury—Most sports-related hernias occur in the groin and don’t appear as a bulge. But if left untreated, it can evolve into an inguinal hernia[3].

Types

  1. Inguinal hernia (found in groin) - the intestine or the bladder protrudes through the abdominal wall or into the inguinal canal in the groin may reach the scrotum.
  • About 96% of all groin hernias are inguinal, and most occur in men because of a natural weakness in this area.
  • Post-thoracotomy lung herniation.jpeg
    Risk factors: older adults; people with close relatives who have had inguinal hernias; people who have had inguinal hernias previously; males; smokers, as chemicals in tobacco weaken tissues, making a hernia more likely; people with chronic constipation; premature birth and low birth weight; pregnancy.[1]

2. Incisional hernia - the intestine pushes through the abdominal wall at the site of previous abdominal surgery. Image R - Post-thoracotomy lung herniation in emaciated patient

  • This type is most common in elderly or overweight people who are inactive after abdominal surgery.
  • Because an incisional hernia is the result of surgery, the clearest risk factor is a recent surgical procedure on the abdomen.
  • People are most susceptible 3-6 months after the procedure, especially if: they are involved in strenuous activity; have gained additional weight; become pregnant. These factors all put extra stress on tissue as it heals.[1]
Hiatus hernia.png

3. Femoral hernia (found in groin) - occurs when the intestine enters the canal carrying the femoral artery into the upper thigh.

  • Femoral hernias are most common in women, especially those who are pregnant or obese.

4. Umbilical hernia - part of the small intestine passes through the abdominal wall near the navel.

  • Common in newborns.
  • Umbilical hernias are most common in babies with a low birth weight and premature babies.
  • In adults, the risk factors include:being overweight; having multiple pregnancies; being female.

5. Hiatal hernia - a hiatal or hiatus hernia is caused by the upper part of the stomach pushing out of the abdominal cavity and into the chest cavity through an opening in the diaphragm.[1].

  • The risk of hiatal hernia is higher in people who: are aged 50 years or over; have obesity.[1]

Image on R Schematic diagram of different types of Hiatal Hernias - Green is the esophagus, red is the diaphragm, blue is the HIS-angle. A is the normal anatomy B is a pre-stage C is a sliding hiatal hernia D is a paraesophageal type

Prevention

Tips to Decrease the Risk of a Hernia

  • Maintain a healthy weight. Rapid weight loss and weight gain place pressure on the abdominal wall.
  • Don’t smoke.
  • Lifting mechanics.jpg
    Change lifting stance. Lift with the legs, not the back.
  • Change your diet to improve bowel movements. Increasing fiber intake may help to relieve constipation that can cause straining during bowel movements, which can aggravate a hernia. Some examples of high-fiber foods include whole grains, fruits, and vegetables.
  • Dietary changes can also help with the symptoms of a hiatal hernia. Try to avoid large or heavy meals, don’t lie down or bend over after a meal, and keep your body weight in a healthy range.
  • To prevent acid reflux, avoid foods that may cause it, such as spicy foods and tomato-based foods.[2]

Treatment

Whether or not surgery is performed depends on the size of the hernia and the severity of symptoms.

  • The doctor may want to simply monitor your hernia for possible complications ie watchful waiting.
  • In some cases, wearing a truss may help to ease the symptoms of a hernia (supportive undergarment that helps to hold the hernia in place).
  • If you have a hiatal hernia, over-the-counter and prescription medications that reduce stomach acid can relieve discomfort and improve symptoms. These include antacids, H-2 receptor blockers, and proton pump inhibitors.[4]

If the hernia is growing larger or causing pain surgeons may decide it’s best to operate. Repair may be by sewing the hole in the abdominal wall closed during surgery. This is commonly done by patching the hole with surgical mesh.

Hernias can be repaired with either open or laparoscopic surgery.

  • Laparoscopic surgery uses a tiny camera and miniaturized surgical equipment to repair the hernia using only a few small incisions. It’s also less damaging to the surrounding tissue.
  • Open surgery, the surgeon makes an incision close to the site of the hernia, and then pushes the bulging tissue back into the abdomen. They then sew the area shut, sometimes reinforcing it with surgical mesh. Finally, they close the incision[4].

Diagnostic Procedures

Can include ( after medical history taken)

  • abdominal ultrasound - high-frequency sound waves to create an image of the structures inside the body
  • CT scan, which combines X-rays with computer technology to produce an image
  • MRI scan

If a hiatal hernia is suspected other tests that allow them to assess the internal location of your stomach may be ordered:

Gastrografin or barium X-ray, which is a series of X-ray pictures of your digestive tract. The pictures are recorded drinking a liquid containing diatrizoate meglumine and diatrizoate sodium (Gastrografin) or a liquid barium solution. Both show up well on the X-ray images.

Endoscopy, which involves threading a small camera attached to a tube down the throat and into esophagus and stomach.[4]

Physical Therapy Management

The main goal of physiotherapy is to:

Reduce pressure off the tissue (e.g. addressing poor breathing mechanics)

4 plank.JPG

Strengthen the supporting tissue (e.g. deep core strengthening)

Apply compression support to assist

Reduce aggravating activities and gradually re-introduce eg Avoid eg weight lifting or exercises that strain the abdomen, may increase pressure at the area of the hernia (cause the hernia to bulge more). The same is true for exercises that are done improperly.

  • Exercise may work to strengthen muscles around the hernia and promote weight loss, helping reduce some symptoms.
  • A study from 2018[4]investigated the effects of an exercise program on obese individuals who were to undergo ventral hernia repair surgery. It was observed that people who completed the exercise program had less complications following surgery.

Hernias in the Elderly

Older person.jpg

Hernias can happen at any age, but this medical condition is very common among the elderly.

  • When a hernia is left untreated, it can result in serious health complications, including debilitating pain, infections, and blood loss.
  • One of the biggest risk factors for hernias is an individual’s age. Older adults tend to have much weaker core muscles, and it doesn’t take much for soft tissue to push through the abdominal wall. Many older adults also undergo procedures that weaken the midsection and tear some of the nearby connective tissue. Seniors who have a family history of hernias must keep an eye out f or lingering discomfort in the midsection and unusual protrusions.[5]
  • Frail seniors who have hernias should not exert themselves and consider professional in-home care when managing daily activities.
    Hernia locations.jpg

Clinical Bottom Line

  • Hernias are usually straightforward to diagnose, simply by feeling and looking for the bulge.
  • Treatment is a choice between watchful waiting and corrective surgery, either via an open or keyhole operation.
  • For a hernia without symptoms, the usual course of action is to watch and wait, but this can be risky for certain types of hernia, such as femoral hernias.
  • Within 2 years of a femoral hernia being diagnosed, 40 percent result in bowel strangulation.
  • It remains unclear whether non-emergency surgery is worthwhile for hernia repair in cases of an inguinal hernia without symptoms that can be pushed back into the abdomen.
  • Education re prevention and appropriate exercises is key.[6]

R image Hernia Locations


References

  1. 1.0 1.1 1.2 1.3 1.4 medical news today Hernias Available from:https://www.medicalnewstoday.com/articles/142334#overview (last accessed 22.5.2020)
  2. 2.0 2.1 wdmed Hernias the basics Available from:https://www.webmd.com/digestive-disorders/understanding-hernia-basics (last accessed 21.5.2020)
  3. Utahhealth Hernias Available from:https://healthcare.utah.edu/healthfeed/postings/2018/02/hernia.php (last accessed 21.5.2020)
  4. 4.0 4.1 4.2 4.3 Healthline Hernias Available from:https://www.healthline.com/health/hernia#treatment (last accessed 21.5.2020)
  5. Home care assistance Hernia Available from:https://www.homecareassistancerockwall.com/identify-and-treat-hernias-in-elderly-people/ (last accessed 22.5.2020)
  6. Verhaeghe PJ, Andriamihamisoa TB, Ralaimiaramanana FM. Hernias in the Elderly. InAbdominal Wall Hernias 2001 (pp. 643-645). Springer, New York, NY. Available from:https://link.springer.com/chapter/10.1007/978-1-4419-8574-3_96 (last accessed 22.5.2020)