Epigastric hernia

Overview

Defect in the linea alba (between xiphisternum and umbilicus) allowing pre-peritoneal fat to herniate through. Peak incidence ages 2-5 years; slightly more common in males.

Presentation

•Midline epigastric lump - firm, between xiphisternum and umbilicus

•Positive cough impulse - more prominent on straining or crying

•Majority asymptomatic - incidental finding by parents

•Firm consistency - content is fat, not bowel

•Reducible in smaller hernias; incarcerated hernias are tender and irreducible

💡

Incarceration of pre-peritoneal fat is the most common complication - causes localised pain and tenderness. Bowel strangulation is rare as the narrow defect typically only admits fat.

Investigations

•Clinical diagnosis in the vast majority - midline lump with cough impulse; no investigation required in straightforward cases

•Ultrasound - if diagnosis uncertain or to confirm hernia contents (fat vs bowel) and exclude other epigastric masses

•CT abdomen - rarely needed; if ultrasound inconclusive or concern about bowel involvement/strangulation

Differential Diagnosis

•Diastasis recti - widening of the linea alba, NOT a true hernia; no hernia neck, no strangulation risk; ridge prominent when child lifts head supine; no surgical repair needed

Management

🥇 First-line

•watchful waiting with parental reassurance - for small, asymptomatic, easily reducible hernias; advise return if painful or irreducible

🥈 Second-line

•elective surgical repair - for symptomatic, enlarging, or non-reducing hernias; fascial defect closure, day-case under general anaesthesia

•Emergency surgical repair - for acutely incarcerated or strangulated hernias; release of incarcerated content and fascial closure; bowel resection rarely required

⚠️

Unlike umbilical hernias, epigastric hernias do NOT reliably close spontaneously - watchful waiting is appropriate for asymptomatic cases, but spontaneous resolution should not be expected.