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Clinical Summary

The umbilicus is a common site of abdominal hernias. Predisposing conditions in adults include ascites and prior abdominal surgery. The size of the defect determines the symptomatology and incidence of incarceration, with smaller defects resulting in more pronounced symptoms and an increased incidence of incarceration. Pain is located in the area of the fascial defect. Contents of the hernia may be palpable and tender. Symptoms of obstruction (nausea, vomiting, and abdominal distention) may be present. If the hernia becomes strangulated, erythema of the overlying skin with fever and hypotension may occur.

Flood syndrome is a rare complication of chronic and recurrent ascites. It is named after the sudden rush of fluid that accompanies spontaneous rupture of an umbilical hernia. Complications include cellulitis, peritonitis, evisceration, and sepsis. Ulceration or necrosis of an umbilical hernia signals impending rupture.

Large-volume paracentesis can precipitate incarceration or strangulation in patients with ascites and an umbilical hernia.

Management and Disposition

Reduction is attempted in the stable patient without clinical evidence of strangulation. Treatment of any predisposing conditions (eg, abdominal paracentesis in the patient with tense ascites) may cause spontaneous reduction and avoid progression of the hernia to strangulation. Routine consultation for elective repair is indicated in asymptomatic patients with reducible hernias.

FIGURE 7.59

Strangulated Umbilical Hernia. The skin overlying a strangulated umbilical hernia is erythematous and tender. (Photo contributor: Lawrence B. Stack, MD.)

Pearls

  1. Umbilical hernias in children usually resolve without treatment.

  2. Umbilical hernias in adults usually become worse and require elective repair.

  3. Eighty percent of flood syndrome is preceded by umbilical hernia necrosis.

FIGURE 7.60A

Umbilical Hernia. A 53-year-old man with umbilical pain and swelling. (Photo contributor: Lawrence B. Stack, MD.)

FIGURE 7.60B

Umbilical Hernia CT Scan. CT reveals omentum in the umbilical hernia defect (arrows). (Photo Contributor: Lawrence B. Stack, MD.)

FIGURE 7.61

Flood Syndrome. Patient with umbilical hernia and ascites with fluid leaking from the stump. This photograph was taken shortly after a large gush of fluid came from the opening in the stump. (Photo contributor: Thomas E. Davis, MD.)

FIGURE 7.62

Umbilical Hernia with Incarceration. Large-volume paracentesis has induced this incarcerated umbilical hernia. Hernia reduction during early phases of paracentesis may prevent incarceration. (Photo contributor: Emily A. Long, MD.)

FIGURE 7.63

Umbilical Hernia with Incarceration—CT. Axial and sagittal CT cuts demonstrating an umbilical hernia in a patient with ascites. (Photo contributor: Emily A. ...

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