Epigastric Hernia

A 48-year-old woman complained of dull, aching abdominal pain and epigastric swelling. She had a 6- to 7-month history of painless swelling that intermittently decreased in size. The patient denied vomiting and nausea. Dr Virendra Parikh of Fort Wayne, Ind, found a slightly tender, vague epigastric mass that extended to the right upper quadrant. Signs of peritonitis were absent. An axial CT image of the lower abdomen revealed a soft tissue mass arising from the midline and extending to the right side within the subcutaneous fat superficial to the abdominal wall musculature. A defect in the linea alba was noted. The mass did not contain contrast-filled loops of bowel. These findings indicated that the mass represented herniated omentum through the linea alba defect. An incarcerated epigastric hernia was diagnosed. The linea alba is a strong, relatively avascular layer of fascia that extends from the xiphoid process to the symphysis pubis. An epigastric hernia occurs when a defect in the linea alba allows preperitoneal fat to protrude through it. Many of these hernias are asymptomatic and are found only on physical examination. Paradoxically, unlike small hernias, large epigastric hernias cause pain infrequently and rarely become incarcerated. This patient’s reducible hernia had existed for some time; only the onset of pain prompted her to seek medical evaluation. The hernia was repaired; the patient’s recovery was uneventful.