Episode 112: When It’s Not a Hernia | Hernia Talk Live Q&A

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Speaker 1 (00:01):

Why hello there. It’s Dr. Towfigh. Welcome to Hernia Talk Live, our weekly Q&A. My name is Dr. Shirin Towfigh. I am your hernia and laparoscopic surgery specialist. Thanks to everyone for joining me live on Facebook Live as well as on Zoom. Many of you also follow me on my other social media platforms, both Twitter and Instagram at hernia doc. As always, I will try to upload all our sessions on YouTube because I have a YouTube channel and it has all over 100 episodes of Hernia Talk Live Q&A. So welcome everyone. Today’s going to be fun because we’re going to talk about things other than hernias. So every week we talk about hernias, how to diagnose hernias, how to, what’s the best imaging, what kind of symptoms would you have, who’s the best surgeon to see? And so on. But lately I’ve been seeing a slew of patients that don’t have hernias but are sent to me because their doctors think they have hernias or they’ve been reading online with Dr. Google and they think they have a hernia and so on. And so I thought I always say hashtag, it’s not just a hernia because I feel like hernias don’t get enough of the kind of prominence and fame that it deserves and not enough of the attention that it deserves. And people think, oh, it’s just a hernia and either don’t pay enough attention to it to get early care. Or even some surgeons kind of play it off like, oh, it’s not that big of a deal, so I’m doing a heart transplant or neurosurgery.

Speaker 1 (01:42):

And then sometimes you get complications and now it really is a big deal. However, I would like to say that sometimes it really isn’t a hernia and this week has been, this past week has been a storm of patients, many of whom had no hernia at all, but rightfully so thought they may have had a hernia. And so the plan today is to go over multiple diagnoses that can mimic hernias and hernia pain and hernia bulging, but are not really hernias. And so it’s kind of like my, as you know, I like to solve mysteries and when people come in, they tell me their story. It’s all about the story. And the story is just not just perfectly right, you know. And so I’ll share some patient stories with you and hopefully you can relate and in doing so, help teach you things that are not hernias. A very common thing I get is upper abdominal pain. So Doc, I got this hernias right here in the right upper abdomen or left upper abdomen. Now you must know that unless you’ve had surgery in a specific area

Speaker 2 (02:59):

Where you can have a surgical hernia induced hernia or what we call incisional hernia. Other than that, it’s really hard to get a hernia just anywhere. It’s just not possible. And what happens actually is that you can only get hernias in certain anatomical areas. So commonly it’s the belly button, it’s also the groin area. There are certain rare hernias just to the side of the abdomen and maybe some in the kind of upper midline, but you can’t get hernias anywhere. And so once you have pain or symptoms in an area that’s not an atomically correct for hernia, that’s when you or the surgeon needs to start thinking maybe it’s not a hernia, maybe it’s something else. And the most common one that I get here is under the ribcage or just below the ribcage on either the left or right side. The most common reason that I hear is, oh, I feel this bulge.

Speaker 2 (03:58):

And actually if you feel it, you can feel it’s almost like a fullness or a bulge in the area. But why would they have that? You can’t randomly get hernias even if they had a really, really bad trauma. Under the ribcage is not a place where even traumatic hernias can occur where you can tear the muscle. So those often are just simply muscle spasm and people get muscle spasm for various reasons, whether it’s pain the area or a reaction to some back spasm or something like that. But abdominal wall pain in the kind of what we call, so underneath a ribcage is often just a muscle spasm. And if you treat the muscle spasm by deep massaging, waling a dry needling, physical therapy, I mentioned deep massage and then some creams, there’s ale, has a cream over-the-counter cream, C B D creams, these are all anti-inflammatory creams, maybe even a muscle relaxant.

Speaker 2 (05:03):

Those can help treat the muscle spasm in the area and directly. So that’s the most common, it’s like a non-surgical problem, but it hurts people. I recently had a patient who had severe kind of ribcage pain. She was right here at the bottom of my rib on the right side. It hurts, you can’t touch it, it’s so painful to the touch. And she’s had so much imaging, all of which were negative and and she’s like, maybe I have what’s called slipping rib syndrome. So slipping rib syndrome is a kind of joint issue. The joint where, so the ribs is a bone and it attaches to two joints in your spine to your spine, vertebral body in your spine, and it attaches to the cartilage in the front of the rib. And most people, unless they have a trauma, should not have any problems with that.

Speaker 2 (06:06):

But every so often, people, especially if they have a connective tissue disorder, let’s say Ehlers Danlos syndrome can get a laxity of that joint or they can have arthritis at that joint or you can have trauma at that joint. And what happens is every time you take a deep breath or if you talk loudly or even if you eat the action of expanding your chest wall will cause pain. The key to this is the pain is not only in the front but it’s also in the back because there’s a joint in the front and there’s a joint in the back and moving either of them can cause pain. So in this patient I thought, okay, it’s not technically slipping rib syndrome because that’s a subluxation or what’s it called? Dislocation at times of the joint. But you can have a fracture. So she ended up, I think she had a fracture of the cartilage and also a dislocation in the back of the joint.

Speaker 2 (07:03):

And that’s something a thoracic surgeon or a spine surgeon can help address. But it was to the point where she was actually being told that, oh, you got chronic pain, you’re going to have to live with it because you have Ehlors Danlos. So that’s just the way it is. And she was told she had nerve blocks, which didn’t work. Of course not because it wasn’t a nerve issue. And then, oh therefore you need a pain pump and you need a nerve stimulator, spinal stimulator, all these things. And she finally came to me and she’s like, maybe it’s a hernia. You know, keep talking about all these misdiagnoses, but you just can’t get hernias there, which is why we started thinking about other things. And if I even brushed the area of her back or the front, it was so painful, so painful, she couldn’t lay on her side wearing a bra would hurt in the area, putting a binder over it actually hurt her more, which is consistent with the fracture.

Speaker 2 (07:59):

So slipping rib syndrome or a dislocation, subluxation of the rib joint can cause upper abdominal kind of under the ribcage pain. Another ribcage pain where some people think, oh, I have a hernia because it hurts and is swollen is when you actually have an inflammation of the joint in the front where the cartilage and the bone joint, that could be from arthritis, especially if you have known arthritis. It can also be from what’s called Tietze syndrome. And Tietze syndrome is really another fan. It’s a fancy term for a costochondritis. So it’s inflammation of the joint between the rib bone and the cartilage and the inflammation can hurt, especially if you touch it or again with coughing or deep breathing or anything that kind of moves your chest while sleeping on that side can hurt. And local anesthetic into the joint can help calm down, especially if you add some steroids the same way you would do for any arthritic joint pain.

Speaker 2 (09:08):

And then you can have, let’s see, what else in the upper quadrants, it could just be simple pain from your stomach or gallbladder. So stomach mostly left upper abdomen, gallbladder mostly right upper abdomen radiates around to your back sometimes or up into the middle chest. You can have peptic ulcer disease, gastric ulcers, gastritis, especially if you overuse anti-inflammatories. But those are not abdominal wall pain. Those are usually deeper pains that are associated with nausea or acid reflux, backwash in the back of the throat and so on while et cetera. And it’s often related to food and certain meals and if you lay down it’s worse and so on. So those are like acid reflux stomach. I had a patient, let’s see what was it this week or last week, she came in convinced she has a hernia, saw her doctor. She indeed had on imaging really, really, really small hernia of her belly button. And she had one pregnancy, which is not enough usually to give you a diastasis, but she did have a little bit of diastasis and they said, ah, it must be her diastasis. But know that diastasis recti is not painful. Almost always not painful. So having a diastasis visually looks weird and people think, oh, you have a separation of the muscle that must hurt. But usually it does not.

Speaker 2 (10:40):

But what can happen is that area can be so thinned that anything that’s going on deep to that becomes more superficially felt. So if you have I’d actually, one patient had her liver in her diastasis and she had hepatitis and actually liver inflammation and she felt it kind of right where her diastasis was in the middle because that was the most superficial you didn’t to the skin. So if you touch that, oh, she was in so much pain and that made sense because you’re basically touching the liver and the liver’s very inflamed. But what was happening is when you have a diastasis, your muscles, your rectus muscles spread apart, but the fascia in between remains and that’s a very thin, so you have skin fat fascia instead of skin, fat, fascia, muscle, fascia. And so the next layer is the organ, I mean stomach or in her case liver.

Speaker 2 (11:39):

And she had hepatitis and that was really her diagnosis, not her hernia or diastasis. So she was sent to me for that problem. So yeah, the patient was so excited, she didn’t have a hernia that needed surgery, she didn’t have a diastasis that required surgery. What she really had was probably acid reflux. So I recommend what, go to your local pharmacy and grab some Prilosec or Protonics or Nexium and see if the pain goes away, start taking some milk of amnesia or Tums, she actually was taking peptos that would help a little bit. GasX helped. So those are all little suggestions that it’s not an abdominal wall issue. All right, so we’re starting at the top and I’m working my way down towards the middle abdomen is like your belly button. So people think, oh, if you have belly button pain must be from a belly button hernia.

Speaker 2 (12:36):

And some people may actually have a belly button hernia because that’s very, very common. But that doesn’t mean necessarily that the belly button is a cause of pain. So patients who have belly button pain, if it’s directly belly button pain and you push on it, it’s often because of that hernia in the area. But a lot of GI problems because of the way the nerves are will cause belly button pain or what we call peri umbilical pain. So for example, classically appendicitis starts with pain around the belly button and then it’s once it becomes worse, you start getting right lower abdominal pain. But the initial presentation of appendicitis is almost always peri umbilical or umbilical pain. Same with ulcers, perforations of the intestine. So having pain at the belly button is commonly associated with GI symptoms and you fix often an infection or something serious.

Speaker 2 (13:37):

Sometimes the hernia or the bulging in the belly button is not from a hernia. So of course hernias are the most common. So you think about it, but a good physical exam is super important. One is you can get lymph nodes that are in the belly button area and they can be inflamed. They’re called Sister Mary Joseph nodes. Cute story back in the day when people started actually cleansing the abdominal wall as part of the preoperative preparation, there was Sister Mary Joseph who would clean the abdominal wall and clean inside the belly button in preparation for the surgeon to do his surgery. Often pancreatic surgery for pancreatic cancer, this was before CAT scan and ultrasound and so on. And she noticed every time she cleaned the people’s belly buns and there was a little nodule in there, they died or weren’t able to have surgery, whereas if there was no nodule, they were more likely to survive the surgery.

Speaker 2 (14:50):

So guess what, that was a lymph node. And so the sister Mary Joseph node is a lymph node from often classically metastatic pancreatic cancer but also from stomach cancer or any other kind of upper GI cancer. So I actually had a patient sent to me with, I had a patient sent to me with a umbilical hernia and I don’t do cancer surgery. There are surgical oncologists that do that for a living and it’s a very, very special practice to have because you’re constantly dealing with patients that are trying to handle a new diagnosis of cancer and you’re able to offer them some hope because you’re the surgeon, but you know, can’t cure everyone for hernia surgery. I don’t get that. So with regard to hernia surgery, my patients are not expected to have diagnosis of cancer. If they do, it’s unrelated to their hernia often and I don’t have to tell ’em they have cancer, but they sent me this patient and I felt her belly, but I was like, oh, that’s not a hernia.

Speaker 2 (16:06):

That is a Sister Mary Joseph note, which implies they have metastatic pancreatic cancer most likely or maybe a bile duct cancer or something in that region. So I called her doctor and she really needed a CAT scan to work it up and so on. And so the thing is, do you go ahead and tell a patient all this information having just met them and not knowing their story and not really having a relationship with them, or do you wait until you get a little bit more information to be able to have much more information to tell them based on CAT scan and blood tests and so on, and that’s what she had done. And it’s kind of weird to come to a doctor’s office expecting a hernia surgery discussion and you’re saying, oh, let’s get more imaging and blood tests and let’s have your doctor follow through with it because you want to make sure that you don’t just say, oh yeah, this is a metastatic lymph node.

Speaker 2 (17:05):

You want to image it and make sure you’re not missing something because the other thing that a bulge or pain or fluid from the belly button can be as a urackal cyst, I hope I’m not throwing out too many weird words out there. I’m trying to go slowly so that everyone can kind of digest this slowly because this is decades of surgical and medical education that I’m sharing with you, but urackal cyst is an extension from your bladder. So most people, their bladders, their bladder and then that’s all where the urine is. But in some patients there’s a little like a straw like connection between the bowel B, the B bladder and the belly button. And if that gets obstructed or it gets infected, they can get a fluid collection, bulging pain and redness, puss in their belly button.

Speaker 2 (18:03):

That’s called ureter cyst. It’s a surgical diagnosis. You need to have it drained any other abscess and potentially have the urackal cyst removed you would any other cyst. It’s a little bit technically complicated because you have to make sure there’s no cancer in that cyst and take the operation down to the bladder, et cetera. I’ve done that before. It’s actually kind of straightforward, but technically you have to do the right thing and you’d be surprised how many people just miss that diagnosis like, oh yeah, I’ve been having this fluid coming out of my bladder, out my belly button every so often. They just told me it’s to clean my belly button more. And I’m like, yeah, normal people don’t just have fluid coming out of their belly button. That’s not normal. So what you have is a ureter cyst and that needs imaging and then incision and drainage and so on. Another one is called, oh, what’s it called? It’s a like a folliculitis of the belly button. I think it’s called osteitis.

Speaker 2 (19:11):

Oh shoot, I had to look that up. So if you’re hairy, if you have a lot of hair, you can also have a lot of hair growing inside your belly button. So you usually male, very hairy belly can happen commonly. And then if you have a lot of hair inside your belly button too, then you can get an ingrown hair and if you get an ingrown hair into your belly button, then that is cause for infection and pain and bulging. And I actually had a young kid actually come to me with exactly that and they thought, oh, he must have a hernia, he must have a strangulate hernia because there’s puss and infection, there’s so much pain and redness and it was so much swelling.

Speaker 2 (20:06):

But what they didn’t understand was this was a totally benign problem and they took him down this totally wrong diagnosis and thought he had all these other things, but it’s basically like a, what do you call an infection like an ingrown ingrown whole ingrown hair within the belly button if you these people, there’s another thing in the kind of back and the lower sacrum where you can get ingrown in ingrown hairs and it’s the same exact process but it’s in the belly button and the treatment is treat the infection, clean out the area, shave it of the skin and then continue shaving the area so that you don’t get these ingrown hairs because it’ll, it’ll continue over and over again.

Speaker 2 (21:04):

Okay, so that’s belly button area. Now let’s go towards the side or kind of the flank area. So we did kind of upper abdomen going down to the belly button. Now we’re going laterally to the sides, which is the flank area. And those are kind of rare areas. Most people do not have bulging or pain on the sides of the abdomen. There are two major reasons why somebody may, the most common, although it’s rare, it’s called acnes, anterior cutaneous nerve entrapment syndrome. So you don’t get bulging with it, but you do get pain classically it’s along the outer edge of your six pack or rectus muscle. Some people may actually have pain kind of halfway inward along that area. It’s usually one specific point area, not multiple areas. And if you point to it, it hurts whenever they engage their muscles. So getting up out of bed, coughing, wearing any constrictive D device over like a belt twisting the abdominal wall, what happens and no one knows why is these little nerves that come from your spine have to go through this little fascial hole to give you sensation to your skin.

Speaker 2 (22:27):

And as they go through that hole, what ends up happening is it gets entrapped and kinked. Kinked is the best term. So it gets kinked in that area. And what happens is every time you contract the muscles, it kinks it more. So if you numb that, if you numb the area, then the pain will go away. Not permanently necessarily, but it’s diagnostic. So a local nerve injection is diagnostic and it can only happen in certain areas. Classically it’s below the belly button, I would say 80 or 90% of the time. Often at times it can be above the belly button and then it would involve specifically using an ultrasound because you know where the nerves run and then just numbing it. And we actually published on this a long time ago and what we found was half of the patients do really well with local block nerve injections and they need maybe three to five injections and they’re done.

Speaker 2 (23:27):

They basically shut down that nerve activity, that hyperactivity and the pain eventually goes away, the other half never get cured. So they’re better with the nerve blocks but they’re not cured. And those people, they actually need the nerve either released or cut. Many of us just cut the nerve because the area, it’s such a small nerve and it’s just a sensory nerve and most people don’t even know they have a problem there. So it’s called acne’s, anterior cutaneous nerve entrapment syndrome. That’s actually a Facebook group about it. Most people on that group tend not to have acnes because it’s a little bit, oh yeah, you have acnes. I have a patient that recently was told he has acnes causing his testicular pain, which I am. I need to get more data to understand that because there is no such nerve that goes to testicle that cause that would be entrapped.

Speaker 2 (24:26):

And he says he’s someone had laparoscopic surgery for it is not laparoscopic, you cannot reach it laparoscopically. It is open surgery. So the details I was getting is a little bit odd, but acnes is one of those diagnoses that need to be considered and a pain doctor often can figure that out. Sometimes other lumps and bumps kind of in the side of the belly or the front of the belly that may not be hernias or it’s just a simple lipoma. You may have heard of a lipoma, it’s like a fatty tumor. It’s often not cancer, it’s just a benign tumor. It’s fatty mass, you can feel it. It’s usually below the skin level but superficial to the muscle wall. But it can be deeper. And you can have tumors that are fatty tumors which are called sarcomas in the abdominal wall that can mimic a tumor, that can mimic a hernia.

Speaker 2 (25:21):

But if you’re careful, what you’ll notice is it’s not really anatomically where the A hernia would be. And so that’s one, it’s much more firm than a hernia would be very, and yet not tender and it’s not as mobile as a lipoma would be. That would be a lipo sarcoma. So definitely have to get imaging before fixing those. I had a patient who came and said, oh yeah, so I had my Spigelian hernia fixed and all of a sudden my antennas went up like, okay, Spigelian hernia, that’s kind of cool. It’s very rare. How often does a patient come in having a Spigelian hernia already? So I took her word for it and then I looked at her scars. I’m like, Ooh, you have a scar and your middle abdomen towards the midline and the upper abdomen Spigelian hernias are typically below the belly button about two finger outs below the button and on the side this is completely different area than a Spigelian her.

Speaker 2 (26:20):

I’m like, oh, you sure it was Spigelian hernia? She said, oh yeah, yeah, the surgeon fixed it. I have a feeling it was just a lipoma knowing the area. I think she just had a lipoma and for some reason the term spa hernia ca came out and the surgery was so long ago, I cannot get the opera report to read it because I’m super curious trying to solve puzzles here. There’s no way that was a Spigelian hernia. It wasn’t even acnes, which is I have a paper written, the title of paper is when it’s not a Spigelian hernia.

Speaker 2 (26:56):

You have to think about acnes anterior cutaneous nerve entrapment syndrome. Guys, if I’m going too fast, let me know because I feel like I’m running through all these case scenarios so quickly. Okay, let’s talk about the lateral area or the flank. So the flank does not naturally get any hernias. However, you can have what’s called flank, sorry, what’s called traumatic hernias from a trauma. But if you just were mining your own business and now you have a bulging in the flank that is a degradation of your muscle until proven otherwise. So basically what’s going on is there’s a nerve that’s being pinched in your spine, kind of sciatica where your nerve is pinched and it causes pain down the leg, but as a nerve that’s pinched higher up in your spine, the same nerve that feeds the muscle to your abdominal wall. Usually that’s like T 8, 9, 10, 11, 12 maybe L1, so T8 to T12 usually or L1.

Speaker 2 (28:07):

And those are very uncommon levels, thoracic levels to have hernias. So it’s uncommon to get to begin with. And then the nerve is pinched but it’s not a sensory nerve, it’s a motor nerve. So the muscle that motor nerve touches is not getting nutrition because the nerve is being pinched because the nutrition is through the nerve and then that muscle weakens and starts to r bulge out similar to a tire if it would have to a weak area of a tire and it would bulge out. So it’s not a hernia because there’s no hole. But what there is is a bulging, and I think I posted one on Instagram recently. The diagnosis is you have to rule out a spinal disorder, you get like a spine CT or MRI and if you’re careful you’ll see that there’s nerve impingement at the level of that what we call dermatome. And then you have spine surgery to release the pressure on that nerve. You would do any disc surgery of the spine and then if you do it early enough, hopefully within the first month to year of diagnosis, then that muscle will kind of regain its function and you’ll go back to normal most commonly. So the treatment is not surgery that of the abdominal wall, the treatment is spine surgery to treat that denervation issue.

Speaker 2 (29:43):

Okay? Two patients this week who had left lower abdominal pain and bulging, they’re both thin and they said, oh, this must be a hernia. And they’ve had hernias before. So they’ve known what a bulge is and actually I think both of them had hernia surgery as well, I have to remember. So they already knew, they’re like, oh, this must be my hernia. It wasn’t so one. Both of ’em had colon issues. So the colon is a large intestine. It is what follows a small intestine. It’s called large intestine because it’s large in width but not long in length. It’s large in width, whereas small intestine is narrower. So the colon is basically your entire large intestine down towards your rectum and then your anus mt the poop. So in one patient intermittently she would get bulging in the area and really sick and then she would get better and then she’ll get bulging in the area again, really sick, then she’ll get better to one point she was in the ER sweating, almost wanted to vomit but didn’t really nauseated white blood cell count was elevated.

Speaker 2 (30:57):

So she had a very redundant colon. So if you have too long of a colon, it can be very, very floppy because there’s only so much space in there for it to go. So it’ll flops on itself because of the extra length and when it flops it can twist on itself. So think of a hose if you have a hose in your garden, if it’s a short hose, it doesn’t tend to twist on itself. But if you have a long hose and you’re trying to go around your garden to water, sometimes a hose twist on itself and it obstructs like a loop. That’s what can happen with your colon. That’s called aureus. So what’s happening is she was intimately izing this very redundant colon. She was a thin lady and so she could tell the bulging and that’s what she was focusing on as opposed to the feeling sick and wanting to vomit part. And so that’s a colorectal surgery problem. I sent her to a surgeon so they can actually remove the redundant extra colon so that she doesn’t end up in the emergency room twisting her colon and being so sick that she needs the emergency surgery. You’d rather deal with these with prior to becoming an emergency.

Speaker 2 (32:18):

The other patient also colon problem, she actually had colon surgery, but the way they sewed her colon back together again caused a very wide reservoir. So she had her normal colon, it emptied into this double, triple, quadruple width reservoir and then that needs to empty down your rectum. And it was hard to do that because just think if you have a big poop in a container that’s four times the size of your normal colon and you’re trying to empty that downstream into a normal colon, that’s going to cause problems. So she also, again, I sent her to a colorectal surgeon to get that address. I joked with one of my colleagues, I’m like, I feel like I’m running a colorectal surgery clinic because literally I’ve seen five patients that all had colon and rectal problems and I’m sending ’em to all my colleagues to try and help them. So they didn’t have hernias. The area where they had bulging and pain was not consistent with the hernia.

Speaker 2 (33:26):

It was very much GI related. And then I got a CAT scan and I was like, oh yeah, this is totally abnormal. Now in both situations the CAT scan was normal. So the situation with the patient that was vulvulizing, it was normal. And the situation of the colon surgery patient with the partial obstruction in this kind of reservoir because of the way it was sewn together was also reportedly normal. The problem is when radiologists read these, they don’t get to examine the patient, they don’t know the story for the patient. And what happens is they just don’t get that answer, that feedback. So it’s a problem because then they basically like, oh, this can be a variant abnormal, but in this patient we know it’s not because of their symptoms. I’m going to go through a couple more scenarios in the pelvis and then we’re going to go straight to your questions because there’s tons of questions that I know are waiting and then happened PR sent to me about, I would say about 15 questions.

Speaker 2 (34:33):

I hope to get through as many as possible. So now we’re going down all the way to the pelvis. And as you know, that’s kind of an area where I enjoy operating. It’s the most complicated area. It has in men, the rectum, the prostate, the bladder, lots of vessels, the hip and women has the hip, the pelvis, the uterus, the ovaries. And so a lot of problems can occur in the pelvis that feels like hernia or groin pain, but it’s not. So from an orthopedic standpoint, and we’ve had Dr. Guy Paiement and Dr. Jason Snibbe as past specialists, superbly intelligent orthopedic surgery doctors that talked about this in detail. But you can have a hip disorder, hip labral, labral tears, hip bursitis, iliopsoas and inflammation and impingement, femoral acetabular impingement. All of these can co from the hip, can groin pain, but it’s really the hip.

Speaker 2 (35:39):

And the key to that is to know the story. Are you limping? Is are you having problems with stairs? Does lying flat make it any better or worse? Depending on those answers, you can kind of figure out it’s the hip and not the groin. Also, from an orthopedic standpoint, you or a rheumatologic standpoint, you can have inflammation of your sacroiliac joint. So in the back it can have SI joint or sacroiliac joint inflammation. We call it sacroiliitis. If you have kind Norwegian or Scandinavian, Northern European genetics ancestry, you may be prone to what’s called ankylosing spondylitis. And that is a rheumatologic disorder that causes inflammation of the SI joint or you can have an infection of the SI joint and all of those can cause not just lower back pain, but pain reading to the groin and inner thigh sometimes into the testicle.

Speaker 2 (36:33):

So that groin pain to the inner thigh is not from a hernia in the groin is really from a SI joint area. Some blood tests like HLAB 27 may be positive in these patients with rheumatoid disorders. There’s urologic problems. So you can have bladder issues, pelvic floor issues, kidney stones can cause groin pain. You can have vascular disorders, aneurysms that can present as groin pain. Some people can have appendicitis. You can have appendicitis in a groin hernia, you actually have a hernia, but that’s not the problem. It’s really appendicitis in the hernia that can cause pain. So those a lot of GI symptoms, Crohn’s disease, ulcerative colitis, you can have abscesses from those that cause pelvic or groin pain. So those are all different diagnoses that a patient may have that may look like a hernia with bulging and pain and inflammation in the area, but it’s not a hernia.

Speaker 2 (37:32):

And you have to address the main problem. And of course in women you have the addition of all the female pelvic organs. Fibroids can really cause a big bulging in the abdominal wall, especially huge fibroids and they can present as bulging, but it’s really not a hernia. The fibroid, you can have endometriosis both in the groin and the round ligament as well as in the pelvis that causes pelvic pain or ovarian cyst that cause pelvic pain really kind of around but really above the level of where a groin hernia would be. And so those are also ovarian torsion, ovarian abscesses, all of these are potential diagnoses that need to be made and the story is the best way to figure these out.

Speaker 2 (38:19):

So I’m going to stop there cause we have about another 20 minutes to go and I know that you have a lot of questions and I want to definitely try and answer those. So we’ll go through some of the questions to help send some of these these queries. So next first question is, given how close the superficial ring is to the pubic bone, this is in the pelvis and the aponeurotic plate that attaches to the pubic bone, how can you distinguish pain from a hernia versus pain from the athletic pubalgia syndrome? So that’s kind of what I’m trying to get at, which is also all of these patients who have non hernia related pain. So superficial ring pain would be Inguinal hernia pain, upper neurotic plate pain would be more of a strain or tear. The history number one is the most important. So history, history, history.

Speaker 2 (39:12):

And what that means is, is the pain directly over the area? How does it radiate? Upper neurotic pain usually doesn’t radiate inguinal hernia. Pain does radiate often into the testicle and around the lower back, whereas a sports train sports strain does not inguinal hernia pain usually is better when you’re lying flat. Sports strain, not necessarily the area of the pain may be different. So if you push directly over the insertion of the rectus or abdominal or the abductor muscles onto the bone and that’s very tender, that’s sports strain. Whereas pain over the inguinal ring is mostly inguinal hernia pain and that’s a little bit more lateral than sports hernia pain. You won’t have pain near the pubic bone. It’s true those two areas are very close, but they’re not exactly overlapping. So there’s a lot of, a lot of difference in that. Imaging will help. Obviously if there’s any question, let’s say you have a soccer player who has such a small hernia, then you can’t really necessarily see it and they’re really more prone to having a sports strain. So imaging is much more helpful in some of these cases.

Speaker 2 (40:32):

The next question is, is also a good one. Is it possible to get, is it possible for a non-athlete to get athletic pubalgia if you lift something too heavy using proform? The short answer is no. Your muscle is not so weak that just lifting anything in including something heavy would cause a tear. To tear muscle off a bone is really, really, really hard to do and you need really, really, really strong muscles to do that. So no, a non-athlete will typically not get athletic pubalgia. So housewife someone who is elderly, they do not get athletic pubalgia, they are not athletic, they’re doing yoga. Pilates is not going to give you athletic pubalgia, but American football would. So it’s a totally different scenario. It’s like it’s a good, it’s trying to tear through an outfit like the incredible Hulk when he takes the shirt and kind of pulls it apart.

Speaker 2 (41:41):

The average person cannot do that. It just takes a lot of might. Here’s another question. Having a pain in my lower abdomen where an inguinal hernias are, I have maybe a tiny bulge, I can’t really be seen. That’s fine. I noticed that when I pushed on the area, I felt something pushed back in like a squishy way that could be inguinal hernia. I have had my appendix removed and I’ve had pain in my pelvic floor and in my hip and I actually have a history of pain in those same areas as well as in my belly button and spine. I don’t know what I should do. My doctor gave me an x-ray and not nothing x-rays show anything you need a CT or MRI or ultrasound. He gave me physical therapy, the pain went away, but stopping, exercised and didn’t know the pain would come back.

Speaker 2 (42:25):

I went back to exercise and felt good and then did weights and it happened all over again. So where the pain is, what the imaging shows, how your pain kind of presents to your story is super important and I don’t want you to feel that, oh, it’s all just the same because I feel that a lot of doctors don’t appreciate the really the fine tuning of all of this. The amount of questions and details we’re actually coming up with a score. I’m super excited. I want to name for it something besides hernia score or Beverly Hills hernia score. Because I’m Beverly Hills Hernia Center. I thought maybe we’ll do Beverly Hills hernia score, but it sounds kind of cheesy. So if anyone has a good idea for a predictive, a name for a predictive hernia score, let me know. But it’s basically going to be an app you plug in your symptoms and it’ll give you a percentage risk of predictive risk. Predictive value as to whether you have a hernia or not.

Speaker 2 (43:36):

I would love for you guys to think of a cute name for it for a hernia predictive score. But the point of that is that it’s all in the history. So your story, what makes it better, what makes it worse, where it radiates and so on. That plus a good physical exam, plus the imaging will help identify and a CT MRI or ultrasound works, X-ray does not work. And well, you should review my imaging Hernia Talk because we reviewed all that. Next one for denervated flank scenario, yes. Do you expect more pain sensation when bowels aren’t emptied? Well, it’s often not painful, it’s just a bulge is a pain more from the denervated flank or the colorectal issue. With colorectal issues, you can get pain with a denervated flank, it’s usually no.

Speaker 2 (44:33):

So if you do have pain and you have denervation injury, then the pain is most likely because you’re constipated and you are locking your core strength. So it’s difficult to empty the colon. You’re getting back pressure from the colon and that’s possibly partly why you’re getting the symptoms. Next question. Why are not physical examination imaging enough to tell when it’s not a hernia? Oh, it’s the story because all about the story, there’s so many people who have hernias and just because you have a hernia doesn’t mean that’s why you have the symptoms. So the problem I see often is people had a hernia, but that wasn’t their problem. They probably had divert. Oh, diverticulitis, we didn’t discuss diverticulitis just recently operated on a patient who had diverticulitis, wasn’t diagnosed with it, and then the pain is left lower abdominal pain and kind of suprapubic pain.

Speaker 2 (45:33):

So pain kind of the middle, which is not consistent with the hernia. They examined him, oh, you have a hernia, let’s fix it. So they did a hernia pair and then that went wrong. He had had multiple surgeries for that. I eventually removed all of his Mesh and just left him be and treated him for his diverticulitis. So that’s another thing. The left floor quadrant pain can be diverticulitis. The point is, it’s your story. How did it start? What makes it better? What makes it work? Does it radiate? It’s all about the story. And that’s why this hernia predictive score we’re coming up with is so, and maybe that’s what we’ll call it, hernia predictive score. It’s such a generic term though. I need a better term. What is the differential diagnosis to be aware of when suspecting a hernia? Is it more frequent to find other illnesses in addition to a hernia or to misdiagnosis as well as a hernia?

Speaker 2 (46:27):

Well, it’s very common to have a hernia. inguinal hernia. Umbilical hernia. And so we reviewed all these differential diagnoses. But what’s crazy is if you have a hernia and in the same area you have a disease, so let’s say what I just sent diverticulitis with a hernia on the same side and you fix a hernia, the pain’s still there and then you start, everyone focuses on the hernia and forgets that, hey, maybe you never had a hernia to begin with. Hip is a big one. So you have a hip disorder, femoroacetabular impingement, hip labral tear, whatever, bursitis. A huge bursitis on this patient. They kept telling him, he says hernia. I’m like, have you seen your hip? It’s so inflamed. Do not have your hernia fixed. None of your symptoms sound like hernia. Hernia symptoms. It’s all hip related. Whenever you move your hip, it hurts you limp. You need a cane that’s not consistent with a hernia. So the key is to figure out which one is a problem and if you can’t figure it out,

Speaker 3 (47:28):

Then really to do the least, the least risky operation first. Hernia assessment wizard. Oh yeah, like the Microsoft Word wizard. We used to have, I remember that you’re aging yourself by the way, because I remember it too. Hernia assessment wizard, HAW. That’s a weird acronym though. I still need a better term for hernia. inguinal hernia, predictive score. And it’s highly sensitive for women and for men. So I’m super eager to launch it, but I need a title. I need a good, good, good. What do you call it? Good name for it. Can a hernia promote or hide other illnesses? Yes. How often have you seen it happen? Okay, so well, this pain with diverticulitis pain patient he’s been having on and off diverticulitis to the point where he went to the emergency room and they’re like, oh yeah, it must be that hernia.

Speaker 3 (48:34):

I’m so sorry. But they just miss the fact that he’s got diverticulitis deep to it. This other lady who kept thinking that, oh, I had a patient today. So the reverse was true. So he had a hernia, but they diagnosed him with, they got a CT scan. The CT scan radiologist didn’t call it a hernia, actually didn’t say there was a hernia or there wasn’t a hernia, just kind of didn’t say anything about hernias, but he did have it on my exam. But he did have diverticulosis, which is a benign disorder and not painful. And they kept telling him, yeah, you have diverticulosis. Diverticulosis. So actually the diverticulosis diagnosis, because it was on imaging was over called and they kept telling him that’s your problem. So now he is all focused on his diverticulosis, but really what it is is he had a hernia. So that one, it was a hernia.

Speaker 3 (49:35):

Okay. Can it be something different from a hernia if a bulge can be seen? Yes. So in the groin, if there’s a, so in general all bulges are not hernias. It could be a denervation injury where you just have weakened muscle. It could be a lipoma or a lipos sarcoma. So basically a fatty tumor, either benign or malignant. It can be an aneurysm or an abscess. Aneurysm is a bulging of the vessels or it can be abscess, which is an infection. Those are the top kind of four or five reasons why you can have bulging. I had one guy that I felt a hernia. I was like, it doesn’t feel right and it turned out to be a cancer or it can be a lymph node. Lymph node is another one. What can I do to keep a hernia from worsening while during the watchful waiting stage? Great question. We could review this on multiple episodes, but you need to make sure all your risk factors for hernia worsening are addressed. No constipation, no chronic cough, no nicotine use.

Speaker 3 (50:42):

If you have sleep apnea, treat that. And if you have diabetes, get that under control. Those are like the top five. And then exercise to maintain your muscle strength and do not gain weight. One exercise or say if you’re do in the gym while watchfully waiting, I have no pain for my direct al hernia. Great. So direct al hernias are weaknesses. They’re not like a punch punched out hole. So the risk of not operating on ’em is very, very low. And so what is best is if you basically want to do watchful reading, any exercise is good. What we do know about exercises is the ones that increase abdominal pressure most include jumping exercises and leg squats. So maybe don’t do those, but honestly, I’m not even sure that the data is accurate. So I say, do whatever you want, really, it doesn’t matter. Be as active as you wish to be and let the pain, which you won’t have with direct ingal hernia lead the way and you should do just fine. Let’s see.

Speaker 3 (51:56):

Let’s see. I think I pretty much addressed everything. That was pretty good guys. I feel like I ran through it so quickly, but there’s so much to cover. There’s so many things that can cause pain, but presented to hernias, and this week I just had a slew, and I’ll tell you the pages were super happy because what happens is they read about it, about hernias and then they get into the whole, don’t use Mesh kind of social media online thing and the Facebook groups and so on. And in doing that, they get really scared like, oh shoot, now I need hernia surgery. They probably want to put Mesh in me and then I’m going to die. So a lot of this kind of work that you do online gets you all hyped up. And then they come to my office, I’m like, actually, you don’t have a hernia and you have colonic volvulus, partial obstruction this week alone.

Speaker 3 (52:57):

Acid reflux gastritis, gender spine disorder, lipoma and acnes. So that was all within the past almost week, which means that there’s a lot that can cause hernias and not, yeah, couldn’t make, you know what? Okay, here’s a comment here. It would make a great grand rounds or conference lecture. I totally agree. Oh, don’t mean a hernia surgeon would be giving a non hernia. Non hernia. I like it. I like it. On that note, I am going to be going to conference the American Hernia Society meeting, which is our annual meeting of hernia related topics in the United States. This year is held in Charlotte, North Carolina. I will be there next week. I will try and fit in one quick hernia talk session before I leave. What am I saying? I’m leaving tomorrow.

Speaker 3 (54:06):

Today is this quick session before I leave. So I’m leaving for Charlotte. I’ll be there for the rest of the week and I look forward to catching up with all my hernia friends and colleagues. Many of them have already been on hernia talk. I hope to recruit more of them to be our guests on hernia talk. Everyone who’s there is really somewhat interested in hernias and often very talented in their field. Mostly general surgeons and some plastic surgeons. So I’m super looking forward to that. I will be live tweeting throughout the meeting. So for those of you who follow me on social media, please follow me on Twitter at Hernia doc. Every time I go to a meeting, I live, tweet from it. And I share with you all the talks and discussions and stuff that we learn. I will be giving two sets of talks.

Speaker 3 (54:58):

One is on imaging MRI use for hernias, and one is on patient outreach, which is what I do here with Hernia Talk Live. So going over the Hernia Talk Live platform and how it’s grown. So I’m super excited to share that with the surgeons and then maybe recruit some more surgeons to come on board, both on hernia talk.com, which is a free discussion form for all of you guys to get your questions answered and get some kind of mentorship and support from your colleagues and friends who’ve been through it before. And I try and answer some questions or a handful of other surgeons are also on the discussion forum. And I’m also running, I think I’m running a session called Groin Pain. I think I’m heading the groin pain session where we talk about evaluation and management of groin pain. And then I’ll be having, I think, a dinner at the NASCAR Hall of Fame.

Speaker 3 (56:05):

And for those of you who know me, you know how much I love cars. I’m totally into cars. You may have heard me give some car analogies. It’s because I like cars a lot, classic cars, vintage cars, but also fast cars and sports cars. So NASCAR is kind of cool. I’m really looking forward to the NASCAR Hall of Fame. So on that note, I will say goodbye. Oh, something interesting. We did this today. We turned in our abstract to the Southern California chapter of the American College Surgeons on this kind of Chinese herbal medicine supplement that we use to help reduce pain after hernia surgery. So that’s kind of something cool that we really liked. And then there’s also some research that we’re working on that’s due next week for sages on gender-based hernia stuff. So super excited about that and lots of deadlines coming, papers we’re writing.

Speaker 3 (57:09):

I’m super excited about all this. I will post about it on my social media. So please do follow me. Like everything I do, I’m going to do some TikTok too. Thank you everyone. You guys have been great. I think I’m enjoying these as much as you are, and I’m so happy to see you all. So that’s the end for tonight. I’m going to fly out tomorrow, go to Charlotte, give some talks, hang out with some hernia people. I’ll share it all on Twitter. Please do follow me on that. Until next week. Oh, next week. Oh, we have a special VIP guest next week international. In fact, it’s so international, we have to do it midday because otherwise the hours won’t work. So next Tuesday at noon a Pacific time, we will have Dr. Ulrike Muschaweck. Woo-hoo. If you guys know who she is, then you know what I’m talking about from Germany. Talk to you next week. Bye everyone.