Further instrument-based examinations, such as an ultrasound examination (sonography), X-ray examination, computed tomography (CT) or magnetic resonance tomography (MRT) are normally not performed in the scope of hernia diagnostics. They may in some cases become necessary though, if the hernia in question is a smaller hernia or internal hernia which the doctor cannot discern at first sight.
Moreover, these further examinations are also used to rule out other diseases in the scope of differential diagnostics and to plan the exact procedure prior to a hernia operation.
Taking the patient's history (case history) constitutes the first step in the process of hernia diagnostics. In order to be able to reliably determine the correct diagnosis and initiate appropriate measures for targeted treatment, the doctor must obtain all important items of information about the patient, his complaint symptoms and his medical history.
For this purpose, the doctor questions the patient in a personal interview (case history interview), on the one hand about the patient's medical history. The purpose of this interview is, among others, to find out whether other diseases are known, whether the patient is taking certain drugs at the present time, or whether the patient is suffering from drug intolerances or allergies. Documents about previous examinations and treatments brought along by the patient, such as medical reports, X-ray findings reports or laboratory results can be very helpful in this context.
On the other hand, the doctor asks the patient to precisely describe the present complaint symptoms. Thus, he may ask for example
- when the complaint symptoms occur
- what kind of symptoms they are
- whether they are permanently present
- what can trigger the pain
If the patient in this context describes symptoms typical of a hernia, then this is a first clue for the treating physician.
If the case history confirms the suspicion of a hernia, then the doctor subsequently performs a thorough physical examination. This normally includes
- the thorough examination of the patient
- palpation of the abdomen
- auscultation of suspicious areas with the stethoscope
- examination of the hernial sac
If a hernia of the abdominal wall is suspected, then the physician will check - mostly with the patient standing upright - whether a protrusion and possibly skin changes are visible. If the protrusion, i.e. the hernial sac, is tender to pressure, then this is an important symptom. In addition, the physician palpates to locate the hernial orifice, the hernial canal and the hernial sac contents of the hernia.
He furthermore checks whether the hernial sac can be displaced back through the hernial orifice to its original position in the abdomen (repositionability). Depending on where the hernia is located, the physician, to this end, turns the skin to the inside at the location concerned.
A hernia can normally be easily diagnosed in such a physical examination. The protrusion is in most cases clearly visible and the herniation site can be easily located by palpation. In order to cause a hernial sac which in itself is inconspicuous to protrude more distinctly and to render it more easy to locate by palpation, the physician may also request the patient to cough or press.
More precise determination
In order to finally determine whether intestinal loops are located in the hernial sac, and whether these may possibly be incarcerated or stuck, the physician auscultates the suspicious regions with the stethoscope. If he hears bowel sounds when doing this, then this is a sign indicative of intestinal loops and possible incarceration.
In the last step, the physician also palpates and percusses the patient's entire abdomen. In this way, he can get an impression of the overall condition of the abdominal wall and may possibly even discover additional hernias.
The physician determines the type of hernia on the basis of the region in which the hernial orifice occurs. Thus, a hernia in the inguinal or groin region for instance is an inguinal or groin hernia. A hernia on the inner side of the thigh is referred to as femoral or thigh hernia. In the navel region, the hernia is referred to as an umbilical or navel hernia. A hernia that occurs on the mid-line of the upper abdomen is referred to as an epigastric hernia.
An ultrasound examination (sonography) can be performed to supplement the physical examination, in order to verify or confirm the findings of the physical examination. This examination is necessary particularly if the hernia is rather small, or if it is an internal hernia that was not readily discernible at first sight in the physical examination, or could hardly be located by palpation. This can for instance be the case in strongly overweight patients, or in the case of a barely palpable femoral hernia.
Ultrasound devices deliver precise images of the inside of the body which enable even minor changes in the organs to be discerned. Hernias, too, can therefore be readily identified with an ultrasound examination. For the patient, sonography is an absolutely pain-free procedure, which is furthermore very sparing, as no X-rays are used.
The X-ray examination is an imaging procedure in which the tissue is exposed to X-rays which traverse the tissue. An X-ray examination renders even minute structures inside the body visible and can thus also clearly detect hernias. In some X-ray examinations, contrast media that contain iodine or barium are additionally used. This is for instance the case in the gastrointestinal passage described in the following.
Gastrointestinal passage for diagnosing a hernia
A gastrointestinal passage is a contrast medium-supported X-ray examination of the upper gastrointestinal tract. It depicts the stomach and the small intestine and facilitates the identification of pathological changes in this region. Intestinal loops that have prolapsed into a hernial sac can also be well depicted and diagnosed with this procedure. A gastrointestinal passage is particularly helpful for diagnosing diaphragmatic hernias and internal hernias.
Since a gastrointestinal passage is associated with a relatively high radiation load, this procedure is only used though if no alternative examination methods for precisely diagnosing a possible hernia are available.
Implementation of an X-ray examination
The patient first ingests a contrast medium and a gas-forming granulate or powder. The purpose of the latter is to fill the organs of the digestive tract with gas, so that their wall structures unfold and irregularities can be better discerned. Once the patient has done this, X-ray images are continuously taken. To this end, the patient assumes various body positions until all sections that are important for the diagnosis of a possible hernia have been recorded in the X-ray images. The doctor monitors the X-ray images that have been taken in parallel on a monitor.
Due to the contrast medium, the patient may briefly suffer from diarrhea and flatulence. The patient should be fasting for the examination, as only in this way a good examination result can be obtained On the day before the examination, the patient should not eat any foods that cause bloating, and on the day of the examination, he must not take any food until completion of the gastrointestinal passage. He should furthermore abstain from coffee, milk and smoking. Medication should not be taken until later, in consultation with the physician.
A computed tomography, referred to in short as CT, is a computer-aided X-ray imaging examination. The CT depicts the human body in cross-sectional images, layer by layer (sectional image procedure). The computed tomography is used primarily in the diagnostics of incisional hernias, parastomal hernias and diaphragmatic hernias. The purpose of the examination is to determine the magnitude and the severity of the diagnosed hernia.
During the examination, the patient lies in a tube-shaped CT scanner. The X-rays are attenuated or weakened to varying degrees when they penetrate the different tissues of the human body. Special detectors record these radiation intensities, and from this information, the device calculates a CT image.
In contrast to a conventional X-ray image, which only depicts coarse structures and bones, even soft tissues are recorded in detail in a CT image. Even minute details can therefore be very clearly discerned on these CT images.
Magnetic resonance tomography
Magnetic resonance tomography, also referred to as nuclear spin tomography, like computed tomography, belongs to the category of the so-called sectional image procedures. These depict the human body layer by layer. In contrast to computed tomography, magnetic resonance tomography does not use X-rays though, but rather uses strong magnetic fields and radio waves.
The patient must therefore take off objects that contain metal, such as jewelry, wrist watches, hearing aids or glasses, prior to the examination. If a patient has a cardiac pacemaker, or if he has metal objects such as plates, screws or nails in his body, then he should, without fail, inform the doctor about this prior to the examination.
Gastroscopy or instrument-assisted inspection of the stomach
Gastroscopy or stomachoscopy is an imaging examination procedure which enables the esophagus, the stomach and the duodenum to be viewed from inside. Small tissue samples for further diagnostics can, if required, also be taken by means of small instruments during a gastroscopy.
An endoscope is used in this procedure. This is a thin tubular examination device which has a miniature camera on its tip. The physician advances the endoscope through the patient's mouth up to the stomach. The stomach should therefore have been emptied completely for this examination. The pictures taken by the miniature camera are transmitted to a monitor.
Gastroscopy serves first and foremost to clarify diaphragmatic hernias: It enables the physician to distinguish between a sliding hernia with reflux of gastric acid into the esophagus (gastroesophageal reflux disease) and a para-esophageal hernia in which a part of the stomach slides up into the chest. This distinction is absolutely essential in order to be able to plan the optimal surgical procedure.
A gastroscopy is normally an examination procedure associated with little stress for the patient. If the patient is nevertheless afraid of the examination, then the patient can be administered a mild sedative, or an anesthetic. The examination then usually takes place in relaxed and pain-free manner.
Measurement of the pH value of the gastric juice
In rare cases, gastroesophageal reflux disease, that is, diaphragmatic hernia (hiatal hernia) with reflux of acidic stomach contents into the esophagus, cannot be conclusively diagnosed, neither by means of a gastrointestinal passage, nor by means of gastroscopy. If this is the case, then a so-called 24-hour pH-metry must additionally be performed. This procedure involves the measurement of the pH-value of the gastric juice over a 24-hour period.
For this examination, a probe is placed in the esophagus in the course of a gastroscopy, and is then left there for 24 hours. How much gastric acid rises up into the esophagus can be determined in this procedure. Under normal conditions, the pH value in the esophagus only rarely lies below 4. If, in the examination, pH values are measured that lie below 4 for a longer period of time, then this is a sign pointing to a disease.