Umbilical Hernia

Gastroenterology (12%) Core Clinical Conditions

1B The Physician Associate is able to identify the condition as a possible diagnosis: may not have the knowledge/resources to confirm the diagnosis or to manage the condition safely, but can take measures to avoid immediate deterioration and refer appropriately.

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Definition Aetiology Pathophysiology Risk factor Sign and Symptoms Investigations Management

An umbilical hernia is a type of hernia that emerges specifically near the navel or the belly button. It occurs when a portion of the intestine or fatty tissue protrudes through a weakened spot in the abdominal wall, resulting in a noticeable bulge. This condition is primarily observed in infants, but it can also affect adults to a lesser degree.
The abdominal wall plays a crucial role in holding the organs within the abdominal cavity in their appropriate positions. However, in the case of an umbilical hernia, this wall weakens near the umbilicus or belly button, creating a gap through which certain abdominal contents can protrude.
Infants are particularly susceptible to umbilical hernias due to the presence of an inherent weakness in the abdominal wall at the site where the umbilical cord was attached before birth. Sometimes, this weakness becomes more pronounced and allows a portion of the intestine or fatty tissue to push through, creating a noticeable bump or bulge.

• Congenital Weakness: One of the most common causes of umbilical hernias is a congenital weakness in the abdominal muscles. In some infants, these muscles may fail to fully develop or close during foetal development, leaving a vulnerable area around the umbilicus. Consequently, this weakness allows the protrusion of the intestine, creating an umbilical hernia.

• Increased Intra-Abdominal Pressure: Factors that exert increased pressure within the abdominal cavity can contribute to the development of umbilical hernias. Chronic conditions such as obesity, constipation, persistent cough, or excessive lifting of heavy objects can place repetitive stress on the weakened abdominal muscles, eventually leading to the formation of a hernia.

• Pregnancy: The physiological changes that occur during pregnancy can also contribute to the development of umbilical hernias. The growing foetus puts strain on the abdominal muscles, potentially causing weakening or separation near the umbilicus. Additionally, the hormonal changes during pregnancy can also weaken connective tissues, further increasing the risk of herniation.

• Age and Muscle Degeneration: As we age, the natural aging process can lead to muscle degeneration, including the weakening of the abdominal muscles. This age-related muscle loss can make individuals more susceptible to the development of umbilical hernias.

• Genetics: While the precise genetic factors are not fully understood, studies have suggested a potential familial predisposition to umbilical hernias. Individuals with a family history of hernias may have a higher likelihood of developing one themselves.

Umbilical hernias are a relatively common condition characterised by the protrusion of abdominal contents through the umbilical ring. While they can occur in people of any age, they are particularly common in infants, especially those under the age of one. To comprehend the pathophysiology of an umbilical hernia, it is necessary to explore the underlying mechanisms contributing to its development.
The umbilical hernia's pathophysiology starts with the weakened abdominal wall near the umbilicus. In normal circumstances, the abdominal muscles and connective tissues work together to maintain the integrity and strength of the abdominal wall. However, certain factors can disrupt this balance, leading to the formation of a hernia.
In infants, the primary cause of an umbilical hernia is the incomplete closure of the umbilical ring during foetal development. During pregnancy, the umbilical cord connects the foetus to the placenta, providing vital nutrients. After birth, the umbilical cord detaches, leaving an opening known as the umbilical ring. Normally, this ring closes within the first few months of life. However, if the closure is incomplete or delayed, it creates a weakened area in the abdominal wall, predisposing the individual to an umbilical hernia.
Several factors can contribute to the weakened abdominal wall seen in umbilical hernias. Genetic predisposition may play a role, as certain families may have a higher incidence of umbilical hernias. Other potential causes include increased pressure within the abdomen due to obesity, pregnancy, or prolonged periods of increased intra-abdominal pressure, such as chronic coughing or straining during bowel movements.
Once the abdominal wall weakens, a hernia may form when abdominal contents, such as a portion of the intestine, fat, or fluid, herniate through the umbilical ring. This herniation occurs because of the pressure exerted by the intra-abdominal organs. The bulging mass that is typically seen in an umbilical hernia represents the protruding contents.
In most cases, umbilical hernias are not painful and can often be easily reduced, meaning that they can be gently pushed back into the abdominal cavity. However, if the herniated contents become trapped, or incarcerated, it can lead to severe complications. Incarceration occurs when the hernial sac constricts tightly around the protruding contents, preventing them from returning to the abdominal cavity. This can compromise blood supply to the herniated tissues, leading to pain, swelling, and potentially necessitating immediate medical intervention.

1. Infancy: Umbilical hernias are most commonly seen in infants, particularly premature babies. The abdominal muscles of infants are often relatively weak, and this weakness can lead to an umbilical hernia. Normally, these hernias resolve on their own as the abdominal muscles become stronger with age.
2. Pregnancy: Pregnant women face an increased risk of developing an umbilical hernia. The growing uterus exerting pressure on the abdominal muscles can weaken the area around the belly button, making it more vulnerable to herniation.
3. Obesity: Excessive body weight and obesity can strain the abdominal muscles, making them more prone to herniation. The added pressure on the belly button region due to excess fat can contribute to the development of an umbilical hernia.
4. Multiple pregnancies: Women who have had multiple pregnancies have a higher risk of developing umbilical hernias. The repeated stretching and straining of the abdominal muscles during each pregnancy increases the likelihood of weakening in the area around the umbilicus.
5. Family history: There appears to be a genetic predisposition to developing umbilical hernias. If a family member, especially a parent or sibling, has had an umbilical hernia, the chances of developing one are slightly higher.
6. Chronic cough or constipation: Conditions that lead to persistent coughing or constipation can increase the incidence of umbilical hernias. The repeated strain and pressure placed on the abdominal muscles during these actions can weaken the area around the belly button.
7. Age: While umbilical hernias are more commonly observed in infants, they can also occur in adults, especially as they get older. With age, the abdominal muscles tend to become weaker, increasing the risk of herniation.

1. Visible bulge or swelling: One of the most noticeable signs of an umbilical hernia is the appearance of a soft lump or bulge near the belly button. This bulge may be more prominent when standing, coughing, or exerting pressure on the abdomen. In infants, the bulge may be more prominent during crying or straining.
2. Pain or discomfort: Some individuals may experience mild to moderate pain or discomfort around the navel region. The discomfort may worsen when lifting heavy objects, coughing, or straining during bowel movements. However, many umbilical hernias are painless and only cause mild discomfort.
3. Redness or discoloration: In some cases, the skin around the hernia may become reddened or discoloured. This can be a sign of a strangulated hernia, which occurs when the herniated intestine becomes trapped and loses its blood supply. Strangulated hernias are considered a medical emergency and require immediate attention.
4. Nausea and vomiting: If the hernia becomes incarcerated or strangulated, it can lead to digestive disturbances such as nausea and vomiting. This occurs due to the compromised blood supply to the herniated tissue, causing abdominal discomfort and gastrointestinal symptoms.
5. Swelling and tenderness: The area around the hernia may become swollen or tender to the touch. Due to the protrusion of abdominal contents, the area may feel firm or tense.
6. Change in bowel habits: Some individuals may experience changes in bowel movements, such as constipation or difficulty passing stool. This can occur when the hernia puts pressure on the digestive system, resulting in altered bowel habits.

History taking:

Enquire about pain, discomfort, or a noticeable bulge near the umbilicus.

Physical examination:

Look for signs of swelling, protrusion, or a visible bulge. They will often ask the patient to cough or strain during the examination to evaluate the reducibility of the hernia. Reducible hernias can be easily pushed back into the abdominal cavity, while incarcerated hernias become stuck outside the abdominal wall and cannot be reduced manually.

Imaging:

Ultrasound or computed tomography (CT) scan. Ultrasound is commonly used to visualise the abdominal wall and differentiate between a hernia and other conditions that may cause a similar bulge. CT scans may be recommended if there are concerns about the size or complications associated with the hernia, or if alternative diagnoses need to be ruled out.

1. Observation and Monitoring

In infants, umbilical hernias often resolve spontaneously within the first few years of life. It is essential to monitor the hernia regularly to ensure it does not pose any immediate risks or complications. Parents should keep an eye on the size and appearance of the hernia, any signs of pain or discomfort, and the ability to reduce the hernia by gently pushing it back into the abdomen. Regular check-ups with a paediatrician are advisable to ensure adequate monitoring.

2. Conservative Approaches

For infants with small umbilical hernias that cause no symptoms or complications, conservative management is typically recommended. This approach involves gentle handling of the hernia, avoiding any activities that might strain the abdominal muscles, and promoting natural healing by ensuring good nutrition and maintaining a healthy weight. Parents should be educated about proper handling techniques and informed about warning signs that require immediate medical attention.

3. Surgical Intervention

If an umbilical hernia persists beyond the age of 4-5 years in a child, causes significant discomfort, becomes incarcerated (cannot be reduced), or shows signs of complications such as pain, redness, or bulging abdominal contents, surgical intervention may be required. The surgical procedure involves repairing the abdominal wall defect and reinforcing the weakened area with sutures or mesh.

4. Lifestyle Modifications

In adults with umbilical hernias, management often involves lifestyle modifications to alleviate symptoms and prevent further complications. Avoiding heavy lifting, maintaining a healthy body weight, doing exercises that strengthen the abdominal muscles, and wearing supportive garments, such as abdominal binders or trusses, are some recommended lifestyle changes. Regular physical activity and a balanced diet can also help reduce the risk of complications associated with umbilical hernia in adults.

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