umbilical hernia
Summary
An umbilical hernia is a protrusion of abdominal contents (typically omentum or bowel) through a weakness or incomplete closure of the umbilical ring. It is common in infants (especially African-American and premature infants) and often resolves spontaneously by age 2-5. In adults, it is associated with increased intra-abdominal pressure states such as obesity, pregnancy, and ascites (e.g., cirrhosis).
Detail
Umbilical hernias result from failure of the umbilical ring to close completely after birth, or from acquired weakness of the fascia at the umbilicus in adults. In neonates, this is a normal variant of development that usually closes by 2-3 years of age due to persistent patency of the umbilical ring; risk factors include prematurity, low birth weight, and African-American ethnicity. Most pediatric umbilical hernias are asymptomatic and resolve spontaneously; surgical repair is considered if the defect persists beyond age 4-5, is large (>1.5-2 cm), or causes symptoms (incarceration, strangulation - though rare in children).
In adults, umbilical hernias are acquired and associated with conditions causing chronically increased intra-abdominal pressure: obesity, multiparity/pregnancy, ascites (commonly from cirrhosis), chronic cough, and prior abdominal surgery. They present as a bulge at the umbilicus, often reducible, that may enlarge with Valsalva. Complications include incarceration (irreducible hernia) and strangulation (compromised blood supply), which is a surgical emergency presenting with severe pain, erythema, and signs of bowel ischemia/obstruction.
Clinically, umbilical hernias in cirrhotic patients with ascites are prone to rupture and are managed with careful diuresis and often elective repair after ascites control, as rupture carries high mortality from peritonitis and fluid loss. Diagnosis is primarily clinical, with ultrasound used if the diagnosis is uncertain or to assess for incarceration/strangulation. Treatment in adults is generally surgical mesh repair given the low likelihood of spontaneous resolution and risk of complications, unlike in children.
Sources
- First Aid for the USMLE Step 1
- Schwartz's Principles of Surgery
- UpToDate: Umbilical hernia in adults and children
- Sabiston Textbook of Surgery
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