Epigastric Hernia

The clinical presentation in both children and adults are practically identical. Most common symptoms are abdominal discomfort and the presence of a painless bulge or swelling in the epigastrium [1]. This protrusion may be very small and may not be initially visible, but masses up 10 cm have been described [5]. The mass is usually reducible, which is a distinguishing feature across all types of hernias. Abdominal pain may be present together with nausea, while acute gastric outlet obstruction has been reported [9].

The single most important step in the diagnostic workup is a thorough physical examination, since an initial diagnosis can be made solely on clinical grounds. Careful inspection and both superficial and deep palpation of the abdomen, with a particular emphasis on the epigastrium and the protracted bulge is essential, and a mass along the linea alba that is reducible when palpated is highly indicative of an epigastric hernia. To confirm the diagnosis, ultrasonography is considered as a simple and effective method, with sensitivity rates approaching 100% [5]. Other imaging studies, such as computed tomography (CT) may also be useful.

Although epigastric hernias are benign and self-limiting occurrences, they may cause discomfort and pain, which is why surgery is performed in virtually all patients, especially in larger forms. The goal is to alleviate discomfort and prevent further herniation through the abdominal wall by providing structural support. Initial approaches included a direct incision and reconstruction of the abdominal wall, but very high recurrence rates (11-20%) led to introduction of novel techniques [2] [8]. Mesh insertion at the site of protrusion has shown substantially lower recurrence rates, and more importantly, this technique was shown to be effective for management of larger and more voluminous hernias [5]. A laparoscopic approach has also been advocated because of very low recurrence rates and very quick recovery [13].

Epigastric hernias are not a life-threatening condition. In fact, 75% of all hernias are considered to be asymptomatic [1], whereas complications such as torsion and strangulation are rare. Incarceration of smaller hernias are common, however [1], but it is often benign and poses little risk. The prognosis may depend on the size and number (approximately 20-25% of epigastric hernias have multiple appearances) or hernias [1], and recurrence rates have shown to be up to 20% [12]. With the introduction of novel surgical methods, such as laparoscopy and insertion of a mesh, substantially lower recurrence rates have been observed [8].

The exact mechanisms that lead to development of epigastric hernia are unknown, but it is established that any weakness, tear, gap or opening in the rectus abdominis muscles on linea alba may lead to protrusion of a sac-like formation [1]. A proposed theory includes changes in decussation patterns of abdominal muscles and fasciae during embryonal development. Epigastric hernias develop between the xiphoid process and the umbilicus and are composed of peritoneal fat, blood vessels and viscera in some cases [1]. They may be present from birth, or they can appear in adulthood, in which case surgery and various predisposing conditions that induce increased intra-abdominal pressure are considered as causative agents [8].

Together with umbilical, incisional and inguinal types, epigastric hernia belongs to the group of ventral abdominal hernias, which are shown to be prevalent in up to 50% of the population [4]. Epigastric hernia alone, however, comprises 0.4-1.5% of all hernias of the abdominal wall [9], emphasizing its rare occurrence. Other reports suggest an overall prevalence rate of 3-5% in the general population [6], but not all patients are symptomatic and hernias may be quite small (15-25 mm) [5]. In children, studies have determined a prevalence rate of 4% across all types of hernias [10]. The diagnosis is most often made between 20-50 years of life and males are significantly more affected than females [1]. Namely, a 3:1 ratio was observed across various studies [1] [2], whereas others claim that the male/female ratio is not in disbalance [11]. Risk factors may represent any condition that puts extensive amounts of pressure on the abdominal wall, such as marked obesity, heavy lifting, ascites and chronic obstructive pulmonary disease (COPD).

Initial theories suggested deformities in the muscular sheaths and their decussation as the primary factor in the pathogenesis model [2]. Namely, the abdominal wall is composed of several aponeurotic and muscular layers that decussate with each other at the linea alba. It approximately 60-70% of individuals, these fibers decussate two or even three times, but in approximately 30-40%, this event occurs only once, thus creating a somewhat weaker spot on abdominal wall through which herniation may occur [2]. This phenomenon was considered to be the main pathological event in the onset of congenital forms of epigastric hernias. Acquired forms, on the other hand, may be induced by surgical procedures that directly cut through the linea alba [8]. Weakness of the abdominal muscles and conditions in which increased intra-abdominal pressure is seen, such as pregnancy [7], but also ascites, COPD, or severe obesity, are shown to be important determinants. Regardless of the cause, a sac-like formation protrudes through the anterior wall and carries fat, blood vessels and viscera in rare cases [1].

Little can be done in terms of preventing congenital forms of epigastric hernia, since factors that lead to its development are not entirely clear. The incidence of acquired forms, however, can be significantly reduced primarily by maintaining adequate strength and stability of abdominal muscles through regular exercise. Additionally, avoiding sudden weight gain and heavy lifting in patients who are not advised to, such as pregnant women or those with recent abdominal surgery, is recommended.

Epigastric hernias belong to the group of hernias that develop on the abdominal wall and occur due to weakness or openings of the abdominal muscles, usually as a result of congenital alterations in decussation of muscle fibers and fascia [1]. It appears on the linea alba and the location may include anywhere from the xiphoid process to the umbilicus [2]. Epigastric hernias are considered to be a rare entity in clinical practice, comprising between 0.35-1.5% of all abdominal hernias and only 8% of hernias that appear on the linea alba [3], but prevalence rates have been shown to be up to 50% according to certain reports [4], presumably because many patients have very small and asymptomatic hernias (15-25 mm) [5]. The majority of studies have determined that a significant predilection toward males exist, with a ratio of almost 3:1 [2]. The highest incidence rates were observed in individuals between 20-50 years [1], whereas cases in both children and pregnant women have been well-described [6] [7]. It is estimated that up to 75% of patients with an epigastric hernia may be asymptomatic [1], while abdominal pain, tenderness, gastric outlet obstruction and a visible and palpable reducible mass are main complaints. The initial diagnosis can be made solely on clinical criteria, whereas a confirmation can be obtained by simple ultrasonography, which has shown to be very effective [2]. Surgical treatment is necessary in virtually all cases and simple approaches such as direct reconstruction followed by suturing were considered as optimal approaches [2]. It is not uncommon for multiple hernias to be identified during ultrasonography and together with the fact that 20% of patients experienced recurrence with classical approaches [2], these facts led to the design of newer techniques, such as insertion of a mesh, resulting in significantly reduced recurrence rates [5]. Although this condition rarely poses any risk for the patient, significant discomfort and symptoms that may be misleading can appear commonly. For these reasons, early recognition through a meticulous physical examination will undoubtedly discover the origin of symptoms seen in epigastric hernia.

Epigastric hernia is a term that describes protrusion of the abdominal wall (herniation) in the epigastrium, the part that lies directly over the stomach. This form of hernia is rarely seen, comprising less than 2% of all abdominal hernias. It can be present from birth, when the presumable cause is malformations of the muscular and connective tissue layers in the midline of the stomach (linea alba), the principal site of its occurrence. Adult forms, on the other hand, can develop after surgical procedures or in conditions that cause increased intra-abdominal pressure. Obesity, ascites, chronic obstructive pulmonary disease (COPD) and pregnancy are all listed as potential risk factors. Epigastric hernia is most commonly diagnosed between 20-50 years of age and it is almost three times more commonly seen in males. Up to 75% of patients do not develop any symptoms, as hernias may be very small (1.5-2.5 cm), but larger protrusions may manifest with abdominal discomfort and pain, as well as nausea and stomach obstruction in rare cases. In virtually all patients, however, a visible bulge on the abdominal midline is observed with the naked eye, which is why physicians must inspect the abdomen in detail when patients are complaining of such symptoms. A distinguishing feature of epigastric (but also all other) hernias is their reducibility, i.e. they will retract on pressure. To confirm the diagnosis, ultrasonography is a simple and accurate imaging procedure, while computed tomography (CT scan) may be used as well. Despite the fact that this condition does not pose any risk for the patient, surgical treatment is indicated in order to reduce discomfort and further growth. Initial surgical approaches have yielded recurrence rates of up to 20%, which led to introduction of novel techniques such as laparoscopy and mesh insertion. The eventual goal is to provide structural support to the weakened part of the abdominal wall and through these approaches, recurrence rates are less than 1%. The single most important step in prevention of epigastric hernias is strengthening of the abdominal walls through regular exercise, whereas at-risk individuals, such as pregnant women, should avoid heavy lifting.

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• Epigastric Hernia or Muscle Strain
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