Hernia

A hernia is a bulge or protrusion of an organ through the structure or musclethat contains it. There are many different types of hernias.

The most familiar are those in which part of the intestines protrude throughthe abdominal wall. An inguinal hernia appears as a bulge in the groin. It can occur with or without pain. Inguinal hernias account for 80% of all herniasand are more common in men, in whom they may descend into the scrotum.

Most hernias result from a weakness in the abdominal wall that either develops or is present at birth. Any increase in pressure in the abdomen, such as coughing, straining, heavy lifting, or pregnancy, can help cause an abdominal hernia. Obesity or recent excessive weight loss, as well as aging and previoussurgery, are also risk factors.

Most abdominal hernias appear suddenly when the abdominal muscles are strained. The person may feel tenderness, a slight burning sensation, or a feeling of heaviness in the bulge. It may be possible to push the hernia back into place with gentle pressure, or it may disappear by itself when the person reclines.

Generally, abdominal hernias need to be seen and felt to be diagnosed. The doctor may ask the person to cough while he or she feels the area. Once a diagnosis of abdominal hernia is made, the doctor will usually send the person toa surgeon for a consultation. Surgery provides the only cure for a hernia through the abdominal wall.

Once an abdominal hernia occurs it tends to increase in size. Some patients with abdominal hernias wait for a while prior to choosing surgery. In these cases, they must avoid strenuous physical activity such as heavy lifting or straining with constipation. They may also wear a truss, which is a support wornlike a belt to keep a small hernia from protruding. People can tell if theirhernia is getting worse if they develop severe constant pain, nausea and vomiting, or if the bulge does not return to normal when lying down or when theytry to gently push it back in place. In these cases they should consult withtheir doctor immediately. But, ultimately, surgery is the treatment in almost all cases.

There are risks to not repairing a hernia surgically. Left untreated, a hernia may become trapped outside the abdomen, causing a blockage in the intestine. If severe enough, it may cut off the blood supply to the intestine and partof the intestine might die. When the blood supply is cut off, the hernia istermed "strangulated." A strangulated hernia is a medical emergency requiringimmediate surgery. Repairing a hernia before it becomes strangulated is muchsafer than waiting until complications develop. The surgeon will push the bulging part of the intestine back into place and sew the overlying muscle backtogether. When the muscle is not strong enough, the surgeon may reinforce itwith a synthetic mesh.

Surgery can be done on an outpatient basis, under either local or general anesthesia, and is frequently done with a laparoscope. In this case, a tube thatallows visualization of the abdominal cavity is inserted through a small puncture wound. Several small punctures are made to allow surgical instruments to be inserted. This type of surgery avoids a larger incision. The prospect ofrecovery is excellent if the hernia is corrected before it becomes strangulated. Abdominal hernias generally do not recur in children but can recur in upto 10% of adult patients.

Some hernias can be prevented by maintaining a reasonable weight, avoiding heavy lifting and constipation, and following a moderate exercise program to maintain good abdominal muscle tone.

A hiatal or diaphragmatic hernia is not visible on the outside of the body. In hiatal hernia, the stomach bulges upward through the muscle that separatesthe chest from the abdomen (the diaphragm). This occurs more often in women than in men.

About 50% of people with hiatal hernias have no symptoms. If symptoms exist they will include heartburn, usually 30-60 minutes following a meal. There maybe some mid-chest pain due to gastric acid from the stomach being pushed upinto the esophagus. The pain and heartburn are usually worse when lying down.Frequent belching and feelings of abdominal fullness may also be present.

With a hiatal hernia, the diagnosis is based on the symptoms reported by thepatient. The doctor may then order tests to confirm the diagnosis. If a barium swallow is ordered, the person drinks a chalky white barium solution, whichwill help any protrusion through the diaphragm show up on the x ray that follows. Currently, a diagnosis of hiatal hernia is often made by endoscopy. This procedure is done by a gastroenterologist (a specialist in digestive diseases). The person is given an intravenous sedative and a small tube is insertedthrough the mouth, then into the esophagus and stomach where the doctor canvisualize the hernia. The procedure usually causes no discomfort. It is doneon an outpatient basis.

Treatments for hiatal hernia include: avoiding reclining after meals; avoiding spicy foods, acidic foods, alcohol, and tobacco; eating small, frequent, bland meals; and a high-fiber diet.

Medications can also help to manage the symptoms of a hiatal hernia. Antacidsare used to neutralize gastric acid and decrease heartburn. Drugs that reduce the amount of acid produced in the stomach (H2 blockers) are also used. This class of drugs includes famotidine (sold under the name Pepcid), cimetidine(Tagamet), and ranitidine (Zantac). Omeprazole (Prilosec) is not an H2 blocker, but is another drug that suppresses gastric acid secretion and is used for hiatal hernias. Metoclopramide (Reglan), a drug that increases the tone ofthe muscle around the esophagus and causes the stomach to empty more quickly.

Hiatal hernias are treated successfully with medication and diet modifications 85% of the time and the prospect of recovery is excellent.

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