Epigastric Hernia: Symptoms, Types, Causes and Treatment

Epigastric hernias are a frequently encountered but often misunderstood type of abdominal wall hernia. Frequently overshadowed by their more famous cousins—inguinal and umbilical hernias—epigastric hernias can present unique diagnostic and therapeutic challenges. In this comprehensive guide, we’ll explore their symptoms, classifications, causes, and the latest evidence-based treatment options, drawing on a range of recent research and expert recommendations.

Symptoms of Epigastric Hernia

Epigastric hernias can be sneaky—many people don’t even realize they have one until symptoms become bothersome or a physician finds it during a physical exam. Understanding the spectrum of symptoms is key for early detection and effective management.

Symptom	Description	Frequency/Notes	Source(s)
Abdominal pain	Vague, intermittent, or localized	Often upper abdomen; can mimic other diseases	1, 2, 10
Palpable lump	Small, midline swelling or bump	Usually above the navel, frequent but not always	2, 14
Gastrointestinal discomfort	Nausea, constipation, or bloating	Less common, may be present in larger hernias	10, 14
Misdiagnosis	Mimics gallstones, ulcers, appendicitis	Can lead to unnecessary exploratory surgery	2, 1

Table 1: Key Symptoms

Common Presentations

Epigastric hernias are notorious for subtlety. Most are small and present primarily as a vague, often intermittent pain in the upper abdomen (epigastrium). This pain is frequently misdiagnosed as stemming from more common conditions like gallstones, peptic ulcers, or even appendicitis, especially if no obvious lump is seen or felt 1, 2.

Palpable Lump and Physical Findings

A classic sign is a small, sometimes tender lump or swelling in the midline of the upper abdomen, typically between the navel and the breastbone. This lump may become more noticeable when standing, coughing, or straining. However, in some cases, especially with small hernias, the lump might not be easily detectable—making careful examination crucial 2, 14.

Gastrointestinal and Severe Symptoms

While most epigastric hernias are asymptomatic or cause mild discomfort, complications can arise. Larger hernias may cause more pronounced gastrointestinal symptoms, such as constipation, nausea, or bloating, especially if bowel or other abdominal contents are trapped 10, 14. In rare cases, severe pain or signs of bowel obstruction may occur.

Diagnostic Challenges

Because symptoms are often vague and overlap with other abdominal conditions, diagnosis can be delayed or missed. This sometimes leads to unnecessary exploratory surgeries when the hernia is not initially suspected 1, 2. Ultrasound has emerged as a highly sensitive, non-invasive tool for confirming the diagnosis 10, 14.

Types of Epigastric Hernia

Epigastric hernias aren’t all the same—they can vary by size, number, and the contents they hold. Understanding these distinctions helps guide management and treatment decisions.

Type	Defining Features	Clinical Significance	Source(s)
Simple	Only preperitoneal fat protrudes	Most common, usually small, less risky	3, 6, 14
Complex	Contains bowel, omentum or rare organs	Higher risk of complications	3, 14, 6
Multiple	More than one defect in linea alba	Requires careful surgical planning	14
With Diastasis	Associated with rectus muscle separation	May need different repair approaches	7, 13

Table 2: Types of Epigastric Hernia

Simple (Fat-only) Hernias

Most epigastric hernias are small and contain only preperitoneal fat. These are generally less symptomatic, although they can still cause discomfort or pain 3, 6, 14. Their main risk is enlargement or increased discomfort over time.

Complex Hernias (With Viscera)

Rarely, the hernial sac contains more significant structures such as small intestine, omentum, or, in exceptional cases, organs like the colon or even a bile duct cyst 3, 6, 14. These “complex” hernias carry a higher risk for complications such as incarceration or strangulation, and their presence can alter surgical planning.

Multiple Epigastric Hernias

About 20% of patients may have multiple epigastric hernias, with several defects along the linea alba (the midline connective tissue of the abdomen) 14. Recognizing this is important, as all defects should be addressed during surgery to prevent recurrence.

Hernias with Diastasis Recti

Diastasis recti—widening of the space between the rectus abdominis muscles—can be associated with epigastric hernias. This changes the structural dynamics of the abdominal wall and may necessitate more extensive repair techniques 7, 13.

Causes of Epigastric Hernia

Why do epigastric hernias form? The answer is multifactorial, involving both anatomical predispositions and acquired risk factors.

Cause Type	Explanation/Mechanism	Predominant Group/Notes	Source(s)
Acquired	Strain, physical effort, chronic coughing	Middle-aged men; laborers	5, 4, 8
Anatomical/Structural	Weakness in linea alba, tension from diaphragm	Men, age 20-50; more common in men	4, 5, 8
Multiple Defect Theories	Vascular lacunae, tendinous fiber decussation	Still debated	8, 4
Rare Congenital	Embryological non-fusion of abdominal wall	Very rare, early-onset cases	5, 8

Table 3: Causes of Epigastric Hernia

Acquired Factors: Strain and Lifestyle

The majority of epigastric hernias develop due to some form of acquired weakness or increased pressure within the abdominal cavity. Acute strain (such as heavy lifting or sudden exertion) can precipitate hernia formation, especially in laborious occupations. Chronic strain—from persistent coughing, constipation, vomiting, or even prolonged illness and weight loss—also increases risk 5.

Anatomical and Demographic Influences

Epigastric hernias are more common in men (2–3 times higher than women), especially between ages 20 and 50 4. The most widely accepted theory is that increased tension in the upper abdominal wall, particularly from the diaphragm’s attachment, creates a weak spot in the linea alba, predisposing to hernia formation 4.

Structural and Theoretical Considerations

There are several anatomical theories explaining why defects occur at specific sites:

• Vascular Lacunae Hypothesis: Small blood vessels create weak points in the abdominal wall 8.
• Tendinous Fiber Decussation Hypothesis: Weakness arises where muscle fibers cross 8.
• No Preformed Sac: Unlike inguinal hernias, epigastric hernias do not have a preformed hernia sac; the defect is mainly in the fascia 5.

While congenital causes are possible, they are exceedingly rare. Most cases present in adulthood and are linked to acquired factors 5, 8.

Treatment of Epigastric Hernia

Treatment strategies for epigastric hernias have advanced, balancing effectiveness with minimizing complications and recurrence. The approach depends on hernia size, symptoms, and associated anatomical features.

Treatment	Indication/Details	Outcomes/Notes	Source(s)
Surgical Repair	Symptomatic, large, or complicated hernias	Low recurrence, high success	14, 12, 13
Simple Suture	Small (<2 cm), single, no diastasis	Suitable in select cases	7, 14
Mesh Repair	Larger, multiple, recurrent, or with diastasis	Lower complications, recurrence	13, 15, 14
Minimally Invasive	E/MILOS, EMILOS, laparoscopic techniques	Low pain, low complication rates	13
Pain Management	Erector spinae plane block, post-op analgesia	Reduced pain, opioid use	11

Table 4: Treatment Options

Indications for Surgery

Not all epigastric hernias require immediate surgery. However, symptomatic hernias, those that are enlarging, or those with complicated contents (such as bowel) should be repaired to avoid risks of incarceration and strangulation 14, 12.

Choice of Surgical Technique

Simple Suture vs. Mesh Repair

• Simple Suture: For small (<1.5–2 cm), isolated hernias without diastasis recti, direct closure with non-absorbable sutures is an option 7, 14.
• Mesh Repair: For larger defects, multiple hernias, or those associated with diastasis recti, mesh reinforcement is recommended. Evidence supports flat polypropylene mesh as having lower complication and reoperation rates compared to patch repairs, with no increase in recurrence 15.
• Recurrence and Chronic Pain: Mesh repairs, especially when placed in the preperitoneal or sublay position (as in MILOS/EMILOS procedures), show very low recurrence and chronic pain rates 13.

Minimally Invasive and Advanced Techniques

Endoscopic-assisted (MILOS), endoscopic (EMILOS), or laparoscopic approaches are increasingly used, especially for patients with multiple defects or diastasis recti. These methods offer excellent outcomes, with minimal complications and rapid recovery 13.

Pain and Postoperative Care

Effective pain control is crucial for recovery. The use of ultrasound-guided erector spinae plane blocks has been shown to significantly reduce pain and opioid requirements after open epigastric hernia repair 11.

Guidelines and Decision-Making

International hernia societies recommend a tailored approach based on defect size, patient anatomy, and presence of associated conditions like diastasis recti. While there is consensus for simple repairs in small, isolated hernias, mesh repair is favored for larger, recurrent, or complex cases 12, 7.

Conclusion

Epigastric hernias, though common, can present subtly and are often overlooked. Their management requires careful assessment and a tailored approach. Here’s a quick summary of what we’ve covered:

• Symptoms: Most are asymptomatic or cause vague upper abdominal pain; diagnosis may be delayed or missed without careful examination or imaging.
• Types: Range from simple (fat-only) to complex (containing bowel or multiple defects), with consideration for associated diastasis recti.
• Causes: Most are acquired, related to abdominal strain and anatomical weak points; men aged 20–50 are at highest risk.
• Treatment: Surgical repair is standard for symptomatic or complicated cases, with mesh repair preferred for larger or complex hernias. Minimally invasive techniques and advanced pain management offer excellent patient outcomes.

A patient-centered, evidence-based approach ensures the best outcomes for those with this underrecognized but important condition.