Epigastric hernia
An epigastric hernia occurs through the midline of the abdominal wall between the navel and the breastbone. It is usually small — often only a centimetre or less across — and it is one of the few hernias where the amount of pain bears no relation to the size of the lump. A tiny epigastric hernia can be genuinely, disproportionately painful, and patients are sometimes told it is too small to matter. It is worth understanding why that is wrong.
How they form
The two rectus abdominis muscles meet in the midline along the linea alba, a band of fibrous tissue formed by the interlacing aponeuroses of the flat abdominal muscles. Between these decussating fibres are small natural gaps, and each gap transmits a small perforating blood vessel and its accompanying nerve.
These vascular openings are the weak points. When intra-abdominal pressure rises repeatedly, a small knuckle of preperitoneal fat is forced through one of them. Initially that is all there is — a fatty hernia with no peritoneal sac at all. Over time the fat drags peritoneum behind it, forming a true sac, which may eventually contain omentum. Bowel is rarely involved, because the defect is usually too small.
The linea alba is widest above the umbilicus, which is why these hernias occur there.
Why small ones hurt so much
This is the point that matters clinically. The defect has a tight, sharp fibrous rim. A small plug of fat forced through it is readily strangulated — not dangerously, since fat is not bowel, but painfully. The trapped fat becomes ischaemic and inflamed, producing sharp, localised, well-pointed pain that the patient can indicate with one fingertip. In addition, the nerve accompanying the vessel through that same gap may be compressed.
So the paradox is explained by the anatomy: a small defect with a tight rim causes more pain than a large defect with a wide neck, because a wide neck lets its contents move freely. Patients are frequently told that a lump this small cannot be causing their symptoms; it very often is.
Multiple defects along the linea alba are common — found in a substantial proportion of patients at operation — and a recurrence is often in fact a second, previously unnoticed defect. This is why the whole midline is examined at surgery.
Risk factors
Obesity, chronic cough, heavy lifting, straining, and an inherently weak or wide linea alba. Epigastric hernia frequently coexists with divarication of the recti, where the midline is stretched and thinned, and with umbilical hernia.
Symptoms
- a small, firm midline lump between the navel and the breastbone, often more easily felt than seen
- sharp, well-localised pain, which the patient can point to precisely
- pain worse on straining, coughing, sitting up from lying, or exertion
- a lump that is often not reducible, because it is a plug of fat rather than a sac of bowel
- tenderness on direct pressure
- sometimes no lump is palpable at all when the patient is lying down — the examination must be done standing and straining
- many are entirely asymptomatic and found incidentally
Because the pain is epigastric, these hernias are not infrequently investigated at length for gallstones, ulcer disease or reflux before the abdominal wall is examined properly.
How the diagnosis is made
Clinical examination, performed with the patient standing and asked to strain or raise their head and shoulders from lying, which tenses the midline and makes the defect palpable. Examining only a relaxed supine patient misses many.
Ultrasound is a useful confirmation, particularly in obese patients, and can demonstrate a small fatty hernia and identify additional defects. CT is used for larger or recurrent hernias and where the diagnosis is uncertain.
Where symptoms are typical of upper abdominal pathology, that should be excluded in parallel rather than assumed away — the two can coexist.
Treatment
Asymptomatic hernias found incidentally may be left alone. Symptomatic ones are repaired, and repair reliably relieves the pain when the diagnosis is correct.
- Suture repair — the fatty plug is excised or reduced and the defect closed. Acceptable for very small defects, though recurrence is higher than with mesh even here, because the underlying tissue is the problem.
- Open mesh repair — a small mesh placed in the preperitoneal or retromuscular plane beneath the defect. This is the standard for defects above about 1cm and is increasingly used for smaller ones too.
- Laparoscopic or robotic repair — for multiple defects, recurrent hernias, obese patients, and where a coexisting divarication is to be addressed at the same time.
The whole linea alba should be assessed at operation, since additional defects are common, and repairing one while leaving another is a recognised cause of apparent early recurrence. Where a significant divarication of the recti is present, repairing the hernia in isolation leaves the weakened midline unaddressed and risks recurrence — a combined repair is often the better plan.
Recovery
Usually a day-case procedure under general or local anaesthesia. Return to desk work within a week or so, and to heavy lifting in four to six weeks. Bruising and a firm ridge at the repair are expected, and settle over months.
Relief of pain is usually immediate and often striking, which is itself confirmation that the hernia was the cause.
When to seek an opinion
A persistent, well-localised midline lump or pain in the upper abdomen deserves examination of the abdominal wall specifically, standing and straining. A lump that becomes acutely painful, red and tender requires prompt assessment, though in practice the trapped tissue is usually fat rather than bowel, so the consequences are pain rather than danger.
Common questions
It is tiny. Can it really be causing this much pain?
Yes, and this is the characteristic feature of this hernia. The opening is small with a tight, sharp rim, so the small plug of fat that comes through it gets pinched and its blood supply squeezed. A large hernia with a wide opening lets its contents move freely and often hurts less. Being told a hernia is too small to explain your symptoms is a common experience and frequently incorrect.
Why can't I push it back in?
Because it is usually a knuckle of fat gripped by a tight fibrous ring, rather than a sac of bowel that can slide back. That is normal for this type of hernia and does not mean it is strangulated in the dangerous sense.
Is it dangerous?
Not usually. The opening is generally too small for bowel to enter, so the serious complication of trapped bowel is uncommon. The problem it causes is pain rather than danger, which is why repair is offered for symptoms rather than as a precaution.
I was investigated for gallstones and an ulcer and nothing was found. Could this be it?
Quite possibly. Pain from an epigastric hernia sits in exactly the area where stomach and gallbladder pain is felt, and the lump is easy to miss unless you are examined standing and straining. If the pain is sharp, you can point to it with one finger, and it is worse on straining or sitting up, the abdominal wall is worth examining carefully.
Do I need mesh?
For anything but the very smallest defect, yes. The tissue in the midline is itself the weak point, so closing it with stitches alone has a higher chance of the hernia returning. A small mesh placed behind the defect reduces that considerably.
Why did it come back so quickly?
Frequently this is not a recurrence at all but a second, separate defect a little further along the midline that was present all along. Multiple small defects are common, which is why the whole midline is checked during the operation.
I also have a gap between my stomach muscles. Does that matter?
It does. A stretched, thinned midline is often present alongside these hernias, and repairing the hernia while leaving the weak midline unaddressed makes recurrence more likely. Where the gap is significant, repairing both together gives a more durable result, and this is worth discussing before the operation.
Will the pain go away after repair?
Usually yes, and often immediately. Reliable relief after repair is one of the more satisfying aspects of this particular operation, provided the hernia was genuinely the source of the pain.
Related conditions
Other conditions of the hernias & abdominal wall covered on this site:
- Inguinal hernia (groin hernia)
- Femoral hernia
- Umbilical and paraumbilical hernia
- Incisional hernia
- Parastomal hernia
- Diastasis recti (divarication of the recti)
- Incarcerated and strangulated hernia
- Rare hernias — Spigelian, lumbar, obturator and others
This page provides general information and does not replace an individual medical consultation. Assessment and treatment are decided for each patient after review of their history and examination.