Barth hernia

Hernia

Definition

Hernia is a general term used to describe a bulge or protrusion of an organ through the structure or muscle that usually contains it.

Description

There are many different types of hernias. The most familiar type are those that occur in the abdomen, in which part of the intestines protrude through the abdominal wall. This may occur in different areas and, depending on the location, the hernia is given a different name.

An inguinal hernia appears as a bulge in the groin and may come and go depending on the position of the person or their level of physical activity. It can occur with or without pain. In men, the protrusion may descend into the scrotum. Inguinal hernias account for 80% of all hernias and are more common in men.

Femoral hernias are similar to inguinal hernias but appear as a bulge slightly lower. They are more common in women due to the strain of pregnancy.

A ventral hernia is also called an incisional hernia because it generally occurs as a bulge in the abdomen at the site of an old surgical scar. It is caused by thinning or stretching of the scar tissue, and occurs more frequently in people who are obese or pregnant.

An umbilical hernia appears as a soft bulge at the navel (umbilicus). It is caused by a weakening of the area or an imperfect closure of the area in infants. This type of hernia is more common in women due to pregnancy, and in Chinese and black infants. Some umbilical hernias in infants disappear without treatment within the first year.

A hiatal or diaphragmatic hernia is different from abdominal hernias in that it is not visible on the outside of the body. With a hiatal hernia, the stomach bulges upward through the muscle that separates the chest from the abdomen (the diaphragm). This type of hernia occurs more often in women than in men, and it is treated differently from other types of hernias.

Causes and symptoms

Most hernias result from a weakness in the abdominal wall that either develops or that an infant is born with (congenital). Any increase in pressure in the abdomen, such as coughing, straining, heavy lifting, or pregnancy, can be a considered causative factor in developing an abdominal hernia. Obesity or recent excessive weight loss, as well as aging and previous surgery, 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 for the person to push the hernia back into place with gentle pressure, or the hernia may disappear by itself when the person reclines. Being able to push the hernia back is called reducing it. On the other hand, some hernias cannot be pushed back into place, and are termed incarcerated or irreducible.

A hiatal hernia may also be caused by obesity, pregnancy, aging, or previous surgery. About 50% of all people with hiatal hernias do not have any symptoms. If symptoms exist they will include heartburn, usually 30-60 minutes following a meal. There may be some mid chest pain due to gastric acid from the stomach being pushed up into the esophagus. The pain and heartburn are usually worse when lying down. Frequent belching and feelings of abdominal fullness may also be present.

Diagnosis

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

With a hiatal hernia, the diagnosis is based on the symptoms reported by the person. The doctor may then order tests to confirm the diagnosis. If a barium swallow is ordered, the person drinks a chalky white barium solution, which will help any protrusion through the diaphragm show up on the x ray that follows. Currently, a diagnosis of hiatal hernia is more frequently made by endoscopy. This procedure is done by a gastroenterologist (a specialist in digestive diseases). During an endoscopy the person is given an intravenous sedative and a small tube is inserted through the mouth, then into the esophagus and stomach where the doctor can visualize the hernia. The procedure takes about 30 minutes and usually causes no discomfort. It is done on an outpatient basis.

Treatment

Once an abdominal hernia occurs it tends to increase in size. Some patients with abdominal hernias wait and watch 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 worn like a belt to keep a small hernia from protruding. People can tell if their hernia 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 they try to gently push it back in place. In these cases they should consult with their 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 incarcerated, which means it can no longer be reduced or pushed back into place. With an incarcerated hernia the intestines become trapped outside the abdomen. This could lead to a blockage in the intestine. If it is severe enough it may cut off the blood supply to the intestine and part of the intestine might actually die.

When the blood supply is cut off, the hernia is termed "strangulated." Because of the risk of tissue death (necrosis) and gangrene, and because the hernia can block food from moving through the bowel, a strangulated hernia is a medical emergency requiring immediate surgery. Repairing a hernia before it becomes incarcerated or strangulated is much safer than waiting until complications develop.

Surgical repair of a hernia is called a herniorrhaphy. The surgeon will push the bulging part of the intestine back into place and sew the overlying muscle back together. When the muscle is not strong enough, the surgeon may reinforce it with a synthetic mesh.

Surgery can be done on an outpatient basis. It usually takes 30 minutes in children and 60 minutes in adults. It can be done under either local or general anesthesia and is frequently done with a laparoscope. In this type of surgery, a tube that allows 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.

A hiatal hernia is treated differently. Medical treatment is preferred. Treatments include:

avoiding reclining after meals
avoiding spicy foods, acidic foods, alcohol, and tobacco
eating small, frequent, bland meals
eating a high-fiber diet.

There are also several types of medications that help to manage the symptoms of a hiatal hernia. Antacids are 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. Another option may be metoclopramide (Reglan), a drug that increases the tone of the muscle around the esophagus and causes the stomach to empty more quickly.

Alternative treatment

There are alternative therapies for hiatal hernia. Visceral manipulation, done by a trained therapist, can help replace the stomach to its proper positioning. Other options in addition to H2 blockers are available to help regulate stomach acid production and balance. One of them, deglycyrrhizinated licorice (DGL), helps balance stomach acid by improving the protective substances that line the stomach and intestines and by improving blood supply to these tissues. DGL does not interrupt the normal function of stomach acid.

As with traditional therapy, dietary modifications are important. Small, frequent meals will keep pressure down on the esophageal sphincter. Also, raising the head of the bed several inches with blocks or books can help with both the quality and quantity of sleep.

Prognosis

Abdominal hernias generally do not recur in children but can recur in up to 10% of adult patients. Surgery is considered the only cure, and the prognosis is excellent if the hernia is corrected before it becomes strangulated.

Hiatal hernias are treated successfully with medication and diet modifications 85% of the time. The prognosis remains excellent even if surgery is required in adults who are in otherwise good health.

Prevention

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.

Resources

Books

Bare, Brenda G., and Suzanne C. Smeltzer. Brunner and Suddarth's Textbook of Medical-Surgical Nursing. 8th ed. Philadelphia: Lippincott-Raven Publishers, 1996.

Key terms

Endoscopy — A diagnostic procedure in which a tube is inserted through the mouth, into the esophagus and stomach. It is used to visualize various digestive disorders, including hiatal hernias.

Herniorrhaphy — Surgical repair of a hernia.

Incarcerated hernia — A hernia that can not be reduced, or pushed back into place inside the intestinal wall.

Reducible hernia — A hernia that can be gently pushed back into place or that disappears when the person lies down.

Strangulated hernia — A hernia that is so tightly incarcerated outside the abdominal wall that the intestine is blocked and the blood supply to that part of the intestine is cut off.

hernia /her·nia/ (her´ne-ah) [L.] protrusion of a portion of an organ or tissue through an abnormal opening.her´nial

abdominal hernia one through the abdominal wall, either a congenital defect or a complication of pregnancy or a surgical incision.

Barth hernia one between the serosa of the abdominal wall and that of a persistent vitelline duct.

Béclard's hernia femoral hernia at the saphenous opening.

Bochdalek hernia congenital diaphragmatic hernia through the pleuroperitoneal hiatus.

cerebral hernia protrusion of brain substance through the cranium.

Cloquet's hernia pectineal h.

complete hernia one in which the sac and its contents have passed through the hernial orifice.

congenital diaphragmatic hernia one due to failure of a foramen in the fetal diaphragm to close when the infant is born; abdominal viscera in the thoracic cavity may cause fatal respiratory failure.

diaphragmatic hernia hernia through the diaphragm.

diverticular hernia protrusion of a congenital diverticulum of the intestine.

epigastric hernia a hernia through the linea alba above the navel.

extrasaccular hernia sliding h.

fat hernia hernial protrusion of peritoneal fat through the abdominal wall.

femoral hernia protrusion of a loop of intestine into the femoral canal.

gastroesophageal hernia paraesophageal h.

Hesselbach's hernia femoral hernia with a pouch through the cribriform fascia.

hiatal hernia , hiatus hernia protrusion of any structure through the esophageal hiatus of the diaphragm.

Holthouse's hernia an inguinal hernia that has turned outward into the groin.

incarcerated hernia a hernia so occluded that it cannot be returned by manipulation; it may or may not be strangulated.

incisional hernia one through an old abdominal incision.

inguinal hernia hernia into the inguinal canal.

intermuscular hernia , interparietal hernia an interstitial hernia lying between one or another of the fascial or muscular planes of the abdomen.

interstitial hernia one in which a knuckle of intestine lies between two layers of the abdominal wall.

intra-abdominal hernia congenital malpositioning of the intestine within the abdomen, with a portion of it protruding through a defect in the peritoneum or being trapped in a sac of peritoneum.

ischiatic hernia sciatic h.

labial hernia one into a labium majus.

mesocolic hernia paraduodenal h.

obturator hernia one protruding through the obturator foramen.

omental hernia an abdominal hernia containing omentum.

ovarian hernia hernial protrusion of an ovary.

paraduodenal hernia an intra-abdominal hernia in which the small intestine rotates incompletely during development and becomes trapped in the mesentery of the colon.

paraesophageal hernia hiatal hernia in which the esophagogastric junction is in place and a small or large part of the stomach protrudes into the thorax.

pectineal hernia a femoral hernia that enters the femoral canal and then perforates the aponeurosis of the pectineus muscle.

perineal hernia herniation of intestine into the perineum through a fissure in the levator muscle and its fascia.

preperitoneal hernia , properitoneal hernia an interstitial hernia lying between the parietal peritoneum and the transverse fascia.

reducible hernia one that can be returned by manipulation.

retrograde hernia herniation of two loops of intestine, with the part between them being within the abdominal wall.

Richter's hernia incarcerated or strangulated hernia in which only part of the circumference of the bowel wall is involved.

sciatic hernia herniation of intestine through the greater or lesser sciatic foramen.

scrotal hernia inguinal hernia that has passed into the scrotum.

sliding hernia hernia of the cecum (on the right) or the sigmoid colon (on the left) in which the intestinal wall forms part of the hernial sac and the rest of the sac is formed by parietal peritoneum.

sliding hiatal hernia hiatal hernia with the upper stomach and the esophagogastric junction protruding into the posterior mediastinum; the protrusion may be fixed or intermittent and is partially covered by a peritoneal sac.

strangulated hernia incarcerated hernia so tightly constricted as to compromise the blood supply of the hernial sac, leading to gangrene of the sac and its contents.

synovial hernia protrusion of the inner lining membrane through the fibrous membrane of an articular capsule.

umbilical hernia an abdominal hernia with intestine inside the umbilicus and the body wall defect and protruding intestine covered by skin and subcutaneous tissue.

hernia u´teri inguina´lis see persistent müllerian duct syndrome, under syndrome.

vaginal hernia vaginocele; a hernia into the vagina.

ventral hernia abdominal h.

her·ni·a (hûr

)

n. pl. her·ni·as

The protrusion of an organ or other bodily structure through the wall that normally contains it.

herni·al adj.

hernia

[hur′nē·ə]

Etymology: L, rupture

protrusion or projection of an organ through an abnormal opening in the muscle wall of the cavity that surrounds it. A hernia may be congenital, may result from the failure of certain structures to close after birth, or may be acquired later in life as a result of obesity, muscular weakness, surgery, or illness. Kinds of hernia include abdominal, diaphragmatic, femoral, hiatal, inguinal, and umbilical. See also herniorrhaphy.

hernia [her´ne-ah]

the abnormal protrusion of part of an organ or tissue through the structures normally containing it. adj., adj her´nial. A weak spot or other abnormal opening in a body wall permits part of the organ to bulge through. A hernia may develop in various parts of the body, most commonly in the region of the abdomen (abdominal hernia), and may be either acquired or congenital. An old popular term for hernia is rupture, but this term is misleading because it suggests tearing and nothing is torn in a hernia. Although various supports and trusses can be tried in an effort to contain the hernia, the best treatment for this condition is herniorrhaphy, surgical repair of the weakness in the muscle wall through which the hernia protrudes.

Bochdalek's hernia congenital posterolateral diaphragmatic hernia, with extrusion of bowel and other abdominal viscera into the thorax; due to failure of closure of the pleuroperitoneal hiatus.

cerebral hernia (hernia ce´rebri) protrusion of brain substance through a defect in the skull.

crural hernia femoral hernia.

diaphragmatic hernia see diaphragmatic hernia.

fat hernia hernial protrusion of peritoneal fat through the abdominal wall.

femoral hernia protrusion of a loop of intestine into the femoral canal, a tubular passageway that carries nerves and blood vessels to the thigh; this type occurs more often in women than in men. Called also crural hernia and femorocele.

hiatal hernia (hiatus hernia) protrusion of a structure, often a portion of the stomach, through the esophageal hiatus of the diaphragm; see diaphragmatic hernia.

Holthouse's hernia an inguinal hernia that has turned outward into the groin.

incarcerated hernia a hernia so occluded that it cannot be returned by manipulation; it may or may not become strangulated. Called also irreducible hernia.

incisional hernia hernia after operation at the site of the surgical incision, owing to improper healing or to excessive strain on the healing tissue; such strain may be caused by excessive muscular effort, such as that involved in lifting or severe coughing, or by obesity, which creates additional pressure on the weakened area.

inguinal hernia hernia occurring in the groin, or inguen, where the abdominal folds of flesh meet the thighs. It is often the result of increased pressure within the abdomen, whether due to lifting, coughing, straining, or accident. Inguinal hernia accounts for about 75 per cent of all hernias.

A sac formed from the peritoneum and containing a portion of the intestine or omentum, or both, pushes either directly outward through the weakest point in the abdominal wall (direct hernia) or downward at an angle into the inguinal canal (indirect hernia). Indirect inguinal hernia (the common form) occurs more often in males because it follows the tract that develops when the testes descend into the scrotum before birth, and the hernia itself may descend into the scrotum. In the female, the hernia follows the course of the round ligament of the uterus.

Inguinal hernia begins usually as a small breakthrough. It may be hardly noticeable, appearing as a soft lump under the skin, no larger than a marble, and there may be little pain. As time passes, the pressure of the contents of the abdomen against the weak abdominal wall may increase the size of the opening and, accordingly, the size of the lump formed by the hernia. In the early stages, an inguinal hernia is usually reducible—it can be pushed gently back into its normal place. Inguinal hernia usually requires herniorrhaphy.

intra-abdominal hernia (intraperitoneal hernia) a congenital anomaly of intestinal positioning, occurring within the abdomen, in which a portion of bowel protrudes through a defect in the peritoneum or, as a result of abnormal rotation of the intestine during embryonic development, becomes trapped in a sac of peritoneum.

irreducible hernia incarcerated hernia.

mesocolic hernia an intra-abdominal hernia in which the small intestine rotates incompletely during development and becomes trapped within the mesentery of the colon.

Morgagni's hernia congenital retrosternal diaphragmatic hernia, with extrusion of tissue into the thorax through the foramen of Morgagni.

paraesophageal hernia hiatal hernia in which part or almost all of the stomach protrudes through the hiatus into the thorax to the left of the esophagus, with the gastroesophageal junction remaining in place.

Paraesophageal hernia. From Dorland's, 2000.

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