hernia

Hernia Overview

 

A hernia occurs when the contents of a body cavity bulge out of the area where they are normally contained. These contents, usually portions of intestine or abdominal fatty tissue, are enclosed in the thin membrane that naturally lines the inside of the cavity. Although the term hernia can be used for bulges in other areas, it most often is used to describe hernias of the lower torso (abdominal wall hernias).

Hernias by themselves may be asymptomatic, but nearly all have a potential risk of having their blood supply cut off (becoming strangulated). If the hernia sac contents have their blood supply cut off at the hernia opening in the abdominal wall, it becomes a medical and surgical emergency.

Different types of abdominal wall hernias include the following:

  • Inguinal (groin) hernia: Making up 75% of all abdominal wall hernias and occurring up to 25 times more often in men than women, these hernias are divided into two different types, direct and indirect. Both occur in the groin area above where the skin crease at the top of the thigh joins the torso (the inguinal crease), but they have slightly different origins. Both of these types of hernias can similarly appear as a bulge in the inguinal area. Distinguishing between the direct and indirect hernia, however, is important as a clinical diagnosis.
    • Indirect inguinal hernia: An indirect hernia follows the pathway that the testicles made during prebirth development. It descends from the abdomen into the scrotum. This pathway normally closes before birth but may remain a possible place for a hernia. Sometimes the hernia sac may protrude into the scrotum. An indirect inguinal hernia may occur at any age.
    • Direct inguinal hernia: The direct inguinal hernia occurs slightly to the inside of the site of the indirect hernia, in a place where the abdominal wall is naturally slightly thinner. It rarely will protrude into the scrotum. Unlike the indirect hernia, which can occur at any age, the direct hernia tends to occur in the middle-aged and elderly because their abdominal walls weaken as they age.
  • Femoral hernia: The femoral canal is the path through which the femoral artery, vein, and nerve leave the abdominal cavity to enter the thigh. Although normally a tight space, sometimes it becomes large enough to allow abdominal contents (usually intestine) into the canal. A femoral hernia causes a bulge just below the inguinal crease in roughly the mid-thigh area. Usually occurring in women, femoral hernias are particularly at risk of becoming irreducible (not able to be pushed back into place) and strangulated.
  • Umbilical hernia: These common hernias (10-30%) are often noted at birth as a protrusion at the bellybutton (the umbilicus). This is caused when an opening in the abdominal wall, which normally closes before birth, doesn’t close completely. If small (less than half an inch) this type of hernia usually closes gradually by age 2. Larger hernias and those that do not close by themselves usually require surgery at age 2-4 years. Even if the area is closed at birth, umbilical hernias can appear later in life because this spot may remain a weaker place in the abdominal wall. Umbilical hernias can appear later in life or in women who are having or have had children.
  • Incisional hernia: Abdominal surgery causes a flaw in the abdominal wall. This flaw can create an area of weakness where a hernia may develop. This occurs after 2-10% of all abdominal surgeries, although some people are more at risk. Even after surgical repair, incisional hernias may return.
  • Spigelian hernia: This rare hernia occurs along the edge of the rectus abdominus muscle, which is several inches to the side of the middle of the abdomen.
  • Obturator hernia: This extremely rare abdominal hernia develops mostly in women. This hernia protrudes from the pelvic cavity through an opening in the pelvic bone (obturator foramen). This will not show any bulge but can act like a bowel obstruction and cause nausea and vomiting.
  • Epigastric hernia: Occurring between the navel and the lower part of the rib cage in the midline of the abdomen, epigastric hernias are composed usually of fatty tissue and rarely contain intestine. Formed in an area of relative weakness of the abdominal wall, these hernias are often painless and unable to be pushed back into the abdomen when first discovered.

Hernia Causes

Although abdominal hernias can be present at birth, others develop later in life. Some involve pathways formed during fetal development, existing openings in the abdominal cavity, or areas of abdominal wall weakness.

  • Any condition that increases the pressure of the abdominal cavity may contribute to the formation or worsening of a hernia. Examples include:
    • Obesity
    • Heavy lifting
    • Coughing
    • Straining during a bowel movement or urination
    • Chronic lung disease
    • Fluid in the abdominal cavity

Hernia Symptoms

The signs and symptoms of a hernia can range from noticing a painless lump to the painful, tender, swollen protrusion of tissue that you are unable to push back into the abdomen—an incarcerated strangulated hernia.

  • Reducible hernia
    • New lump in the groin or other abdominal wall area
    • May ache but is not tender when touched
    • Sometimes pain precedes the discovery of the lump
    • Lump increases in size when standing or when abdominal pressure is increased (such as coughing)
    • May be reduced (pushed back into the abdomen) unless very large
  • Irreducible hernia
    • Occasionally painful enlargement of a previously reducible hernia that cannot be returned into the abdominal cavity on its own or when you push it
    • Some may be long term without pain
    • Also known as incarcerated hernia
    • Can lead to strangulation
    • Signs and symptoms of bowel obstruction may occur, such as nausea and vomiting
  • Strangulated hernia
    • Irreducible hernia in which the entrapped intestine has its blood supply cut off
    • Pain always present followed quickly by tenderness and sometimes symptoms of bowel obstruction (nausea and vomiting)
    • The affected person may appear ill with or without fever
    • Surgical emergency
    • Not all strangulated hernias are irreducible (but all irreducible hernias are not strangulated)

When to Seek Medical Care

 

All newly discovered hernias or symptoms that suggest you might have a hernia should prompt a visit to the doctor. Hernias, even those that ache, if they are not tender and easy to reduce (push back into the abdomen), are not surgical emergencies, but all have the potential to become serious. Referral to a surgeon should generally be made so that you can have surgery by choice (called elective surgery) and avoid the risk of emergency surgery should your hernia become irreducible or strangulated.

If you find a new, painful, tender, and irreducible lump, it’s possible you may have an irreducible hernia, and you should have it checked in an emergency setting. If you already have a hernia and it suddenly becomes painful, tender, and irreducible, you should also go to the emergency department. Strangulation (cut off blood supply) of intestine within the hernia sac can lead to gangrenous (dead) bowel in as little as 6 hours. Not all irreducible hernias are strangulated, but not all cases of strangulation are irreducible hernias.

Exams and Tests

 

If you have an obvious hernia, the doctor may not require any other tests (if you are healthy otherwise). If you have symptoms of a hernia (dull ache in groin or other body area with lifting or straining but without an obvious lump), the doctor may feel the area while increasing abdominal pressure (having you stand or cough). This action may make the hernia able to be felt. If you have an inguinal hernia, the doctor will feel for the potential pathway and look for a hernia by inverting the skin of the scrotum with his or her finger.

Hernia Treatment

 

Self-Care at Home

 

In general, all hernias should be repaired unless severe pre-existing medical conditions make surgery unsafe. The possible exception to this is a hernia with a large opening. Trusses and surgical belts or bindings may be helpful in holding back the protrusion of selected hernias when surgery is not possible or must be delayed. However, they should never be used in the case of femoral hernias.

Avoid activities that increase intra-abdominal pressure (lifting, coughing, or straining) that may cause the hernia to increase in size.

  • A family history of hernias can make you more likely to develop a hernia.

Medical Treatment

Treatment of a hernia depends on whether it is reducible or irreducible and possibly strangulated.

  • Reducible hernia
    • In general, all hernias should be repaired to avoid the possibility of future intestinal strangulation.
    • If you have pre-existing medical conditions that would make surgery unsafe, your doctor may not repair your hernia but will watch it closely.
    • Rarely, your doctor may advise against surgery because of the special condition of your hernia.
      • Some hernias have or develop very large openings in the abdominal wall, and closing the opening is complicated because of its large size.
      • These kinds of hernias may be treated without surgery, perhaps using abdominal binders.
      • Some doctors feel that the hernias with large openings have a very low risk of strangulation.
    • The treatment of every hernia is individualized, and a discussion of the risks and benefits of surgical versus nonsurgical management needs to take place.
  • Irreducible hernia
    • All acutely irreducible hernias need emergency treatment because of the risk of strangulation.
    • An attempt to reduce (push back) the hernia will generally be made, often with medicine for pain and muscle relaxation.
    • If unsuccessful, emergency surgery is needed.
    • If successful, however, treatment depends on the length of the time that the hernia was irreducible.
      • If the intestinal contents of the hernia had the blood supply cut off, the development of dead (gangrenous) bowel is possible in as little as 6 hours.
      • In cases where the hernia has been strangulated for an extended time, surgery is performed to check whether the intestine has died and to repair the hernia.
      • In cases where the length of time that the hernia was irreducible was short and gangrenous bowel is not suspected, you may be discharged.

      o Because a hernia that was irreducible and is reduced has a dramatically increased risk of doing so again, , you should therefore have surgical correction sooner rather than later.

      o Occasionally, the long-term irreducible hernia is not a surgical emergency. These hernias, having passed the test of time without signs of strangulation, may be repaired electively.

Prevention

 

You can do little to prevent areas of the abdominal wall from being or becoming weak, which can potentially become a site for a hernia.

 sumber : e-medicine health

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