Epigastric hernia is the protrusion of preperitoneal fat or abdominal contents through a defect in the linea alba between the xiphoid process and the umbilicus.
Anatomy Involved
Linea alba
Rectus abdominis muscles
Preperitoneal fat
Peritoneum
Boundaries
Anterior → Skin and subcutaneous tissue
Posterior → Peritoneum
Medial → Linea alba
Lateral → Rectus abdominis muscles
Upper limit → Xiphoid process
Lower limit → Umbilicus
Pathology of Epigastric Hernia
Small defects develop in the linea alba
Preperitoneal fat protrudes first through the defect
Peritoneum may follow later
Omentum or small bowel may herniate in large defects
Repeated increase in intra-abdominal pressure enlarges the defect
Types
Fatty epigastric hernia
True epigastric hernia (with peritoneal sac)
Multiple epigastric hernias
Causes / Risk Factors
Congenital weakness of linea alba
Obesity
Chronic cough
Heavy lifting
Constipation
Pregnancy
Ascites
Clinical Features
Small swelling in the epigastric region
Swelling increases on coughing or straining
Pain or discomfort in upper abdomen
Local tenderness
Dyspepsia or epigastric discomfort
Often multiple swellings present
Usually irreducible due to fat entrapment
Physical Examination
Palpable midline swelling between xiphoid and umbilicus
Cough impulse present
Swelling becomes prominent on head-raising test
Usually non-reducible
Diagnosis
Clinical examination
Ultrasound abdomen
CT scan for unclear or multiple defects
Complications
Painful incarceration of fat
Strangulation (rare)
Local inflammation
Increase in size over time
Management
Conservative
Suitable for small, asymptomatic hernias
Avoid heavy lifting
Weight reduction
Treat chronic cough and constipation
Surgical Management
Indicated in symptomatic cases
Herniotomy with closure of defect
Mesh repair for large or multiple defects
Open or laparoscopic approach
Surgical Principles
Identification of defect
Reduction or excision of herniated fat
Closure of linea alba defect
Reinforcement with mesh if required
Homoeopathic Therapeutic Approach
Nux vomica → For abdominal strain and constipation