Episode 71: Abdominal Pain Medical Mystery Solving | Hernia Talk Live Q&A

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Speaker 1 (00:00:00):

Hi everyone. Welcome to Hernia Talk Live. Just want to thank you all for joining me. My name is Dr. Shirin Towfigh. Thank you for joining me every Tuesday live on Facebook or on Zoom, and also for those of you that then watch this pre-recorded on YouTube. Usually I just wanted to thank you all because you’re following me and you’re making me and inspiring me to do more of these talks. Thank you for following me on Twitter and Instagram at Hernia doc on Facebook. And today we will be talking about abdominal pains as a medical mystery. If maybe you’re following me on social media, you’ll see that I’ve been discussing a couple of patients I’ve had recently where they’ve had these medical mysteries of abdominal pain. I think the last one was 17 years of pain, not really knowing what it was and they’ve been through so much.

Speaker 1 (00:01:04):

And so I get many patients like you that reach out to me mostly because I really enjoy solving problems. And I was explaining this to a friend of mine yesterday, a lot of. People see problems and they run away from it. I see a medical problem and I run towards it because even as a child I enjoyed solving puzzles, I would have these little puzzle books, kind of mind twisters. I enjoyed solving crossword puzzles, Sudoku, whatever it is. So I do enjoy figuring out medical mysteries now. It’s been a while since I’ve been in medical school. I graduated medical school in 1996 and ever since then I’ve been a surgeon. So most of what I know of course is surgical. And I have a very narrow specialty, which is hernia surgery. And in that narrow specialty, I really know my stuff on hernias, especially in the groin.

Speaker 1 (00:02:07):

But anything hernia related, I know it and I know all the rare stuff, really rare perineal hernias, petites hernias, lumbar hernias, grynfeltt hernias, all these fancy names for fun hernias that can occur. And I’ve treated them. I’ve treated these rare sciatic notch hernias. And what’s another really rare one? I just listened to the grynfeltt hernia. So what I’m trying to say is I have experience in hernias are really like that’s my thing. And so a lot of people come to me because they think they have a hernia or they haven’t really figured out what the problem is and they’ve seen me write about things or watch me on hernia talk and they’re like, okay, maybe she can figure this out. Maybe what I have is a hernia. You don’t necessarily have a hernia when you come to me, oftentimes I figure

Speaker 2 (00:02:58):

Out another reason for your problem and pain. But what I think people have figured out is I do enjoy the challenge and if it’s a hernia, great, I can fix it. I know all about it. And if it’s not a hernia and it’s outside of my scope, it could be a medical problem, it could be lupus that’s causing your symptoms. I kind of will be able to help you navigate this, the medical system to get you care. So lately I’ve had a handful of really unique medical mysteries that I’ve been able to solve and the patients are alike. I mean one patient is down to 90 pounds because of her mystery abdominal pain and actually hers are more chest pain, but it’s not really abdominal pain, but understanding how the body works and really remembering what they taught you back in medical school or maybe there was this one scenario where you read it somewhere that you’ve remembered or I love doing research, I do my own research.

Speaker 2 (00:03:55):

I presented a lot of talks and then I love Googling things and reading more and reading literature and stuff. So I thought it’d be kind of cool to spend today’s hour talking about abdominal pain and how it can be hernia related versus non hernia related and how to kind of solve medical mysteries because this past several weeks have been a slew of really unique diagnoses that I’ve gone through. And of course if you have any questions that you’d like to submit to me, I will answer them as we go through. But I had some pre-prepared for you and so I thought we’d kind of go through this already. So why is abdominal pain such a medical mystery? And I’d like to tell you it’s because there’s so much going on in the abdomen. Number one, there’s the abdominal wall, which is kind of my territory. There’s the internal organs within the abdominal wall, which is as a general surgeon what we deal with.

Speaker 2 (00:04:56):

But gastroenterologists deal with it, urologists deal with it, gynecologists. Your spine can cause abdominal pain if it’s like a nerve related problem. And then also something that’s very interesting that was taught to me is that the chest is the mirror of the abdomen and the abdomen is the mirror of the chest. So oftentimes, not oftentimes, but it can happen where you actually have a chest problem, but it presents with abdominal pain, very simple pneumonia. Pneumonia can cause abdominal pain. So if you have a left side of pneumonia, you can have left side abdominal pain. If you have a right side of pneumonia, you can have right side of abdominal pain. The reverse is also true. You can have let’s say pancreatitis, which is inflammation of your pancreas and that can cause chest pain in the upper abdomen. And I have one lady recently who has severe chest pain.

Speaker 2 (00:05:56):

Her story is very interesting over the past year and a half or so, she just feels this tightness around her chest. Sometimes it’s difficult to breathe, it gives her nausea. She can’t wear a bra; she can’t really wear any constricting outfits around her chest. And so a lot of the attention has been around her chest and I’m willing to bet, cause I think I solved her medical mystery, which I think is abdominal in nature. But like I said, the chest is the mirror of the abdomen, so a lot of the symptoms she’s getting, even though it’s chest related, she feels like she gets short of breath. She’s otherwise normal and healthy. She gets these weird blood pressure fluctuations. It can be from an abdominal problem. So really interesting stuff. The other reason why abdominal pain is so difficult as a medical mystery I think is as clinicians as doctors we’ve lost, we’ve absolutely lost the talent of diagnosing things based on just sitting and talking to the patient, number one and number two, looking at diagnostically at labs and physical exam.

Speaker 2 (00:07:12):

So when I was in college, yeah, when I was in college I had a mentor, his name was Dr. Solly, I may have mentioned him on this show before he was a nephrologist, the majority of his patients did not have kidney issues, which is what a nephrologist takes care of. He was a super smart doctor. He could just listen to you and examine you and he knew and maybe look at some labs and he knew what was wrong with the, whereas today everyone has to get imaging and they’re not even good at reading the imaging. So it’s like this horrible luck oxymoron where the doctors don’t even touch you anymore. You can’t imagine how many patients I’ve seen were the patient’s like I never got a physical exam and we’ve kind of lost the talent and the technique of doing physical examination and we highly reliant on technology at least in the United States.

Speaker 2 (00:08:17):

Now this doctor mentor of mine training Canada and at McGill, which is a fantastic institution and at that time, at least in the United States compared with Canada, McGill and Canada were much more likely to train really astute clinicians as opposed to the US where we have MRI and CAT scan and PET scan and another MRI and are so reliant on technology. You can’t imagine how many patients I’ve seen that have a hernia in the groin or in the belly. I mean it’s groin pain. Why are you getting colonoscopy, colonoscopy, endoscopy, all these GI studies makes no sense to me because the symptoms associated with the GI are very different often than the symptoms that you have with an abdominal wall problem. So it doesn’t make sense to me sometimes why certain decisions are made and that’s kind of where I am, where I’m at. So I actually enjoy that.

Speaker 2 (00:09:22):

My mentor was my kind of role model for that kind of stuff and I really strongly believe in the history. I think the story, everyone has a story. I need to hear your story. What is the story and what are the little details within the story? What are little tidbits? Some patients come to me and they’re like, I don’t want to overwhelm you with all my story or they don’t tell me certain details because I think it’s going to scare me away and I’m going to be overwhelmed with so much information. And yet that little bit, the fact that going uphills hurts more the fact that liquids hurt, but solids don’t when you have a meal or solid meals hurt, but liquids don’t. Those are little tidbits of information that are really helpful. I had a patient that this is a good one. He was a kid, I think he was 16 or 17 and just the worst abdominal pain, he would get descended too and no one could figure out why he had this abdominal pain.

Speaker 2 (00:10:29):

They sent him to me a little bit chunky kid, overweight and maybe he has a hernia. He didn’t have a hernia, but the tidbit was this. If he had one of these abdominal pain attacks, he would go sit in a hot tub, like a bath, like a bathtub. The mom would say, I would know that he’s feeling bad again when I would hear the bathtub water running and he would sit in a warm bathtub and his pain would be so much better. Does anyone know the diagnosis? That little tidbit alone is the diagnosis. All you have to hear is that I have your diagnosis. So it’s abdominal pain that is better with sitting in a hot bathtub. We’ll sit on that one for a while, we’ll let you munch on it, but it’s little tibit like that really excite me because those are the ones that you’re like, oh, this is so cool. I solved that, cracked the case so to speak. All right, so moving along, how can you differentiate among different diagnoses for abdominal pain? Well, this is a very good

Speaker 3 (00:11:53):

Question because if you have a good clinician, physician, could be a surgeon, doesn’t need to be a surgeon, but someone who could really ask the key questions to then be able to differentiate is this abdominal pain from the GI tract? Is this from the abdominal wall? Then at least that way kind of make the diagnoses down a certain pathway instead of being like, oh, let’s just kind of rule everything up. So for example, abdominal pain that it’s a GI tract is often changes. First of all, it’s never, it’s usually patients will see in my pain is exactly here and it never moves because intestines move and colon moves and so on. So it tends to migrate if it’s the intestinal tract and then where it starts and where it moves is indicative and it’ll shoot towards the back for example, or up towards the chest or down towards the pelvis.

Speaker 3 (00:12:56):

It’s often around the belly button because the nerves all kind of coalesce in that way then whereas abdominal wall pain is almost always activity related, so you’re better when you’re flat and not doing anything. You’re worse when you’re up and about and bending and running or walking, whatever. So a activity related pain is almost never GI tracked, almost never GI tracked with very few exceptions and pain that migrates around is almost never hernia with probably no exceptions. If you got pain, sometimes she have sometimes there a nausea, bloating, that’s usually GI tract. Let’s see, we just got a question. Come on in significant pain, I have significant pain at the xiphoid process, which is that bone right at the bottom of your chest here, right down here and along the left lower rib cage and diaphragm after laparotomy down the midline. Also I have non-functioning abdominal muscles.

Speaker 3 (00:14:04):

Any ideas what can be done? Okay, that’s a good question. So pain of the xiphoid puzzle, which is this bone can be because you actually have a fracture of the xiphoid. So that can happen if you broke it, you know like you got hit somewhere. Let’s say a baseball hit you or if the surgeon went all the way up and fractured that, sometimes by retraction they try to go in there and see what’s what’s up and that bone piece got fractured and some cat scan can show you or a CAT scan or good x-ray can show you if that cartilage there is broken. Sometimes depending on the laparotomy, the laparotomy is goes all the way up. Laparotomy is basically a scar

Speaker 2 (00:14:50):

Usually and down on the abdomen. So if the laparon goes all the way up towards the xiphoid, usually for let’s say abdominal upper abdomen surgery like stomach, pancreas, liver, then sometimes they have to go really high up and the xiphoid is in the way. So they either split the xiphoid or they go to the side of the xiphoid and then at the end they have to close it. And sometimes using the closure, either you get a hernia there and the hernia there can be painful because it’s separated in that area and things try and poke in that area or the way it’s closed, kind of traps that xiphoid process in the repair. So it seems that the pains at the xiphoid process and along the left ribcage or diaphragm after an up and down laparotomy incision and you also have non-functioning abdominal muscles. So I don’t know what you mean by non-functioning abdominal muscles.

Speaker 2 (00:15:49):

If you have an incision this way and incision this way, so an up and down incision and one that crosses it either at an angle or perpendicular, that can cause nerve damage to the muscles because the nerves come in down diagonally. And so if you cut the nerves this way up and down, usually that’s not an issue, but if you cut it up and down and you cross cut it, then this lower corner of that of those two can have no both sets of nerves cut and that can cause non-functioning abdominal muscles. So if you’ve had more than just an up and down laparotomy part of it may be from a hernia and then you know could have adhesions from prior surgery. Is your stomach stuck to that area of the xiphoid process? Often not. It livers usually in the area. And then lastly it could be something deeper to the xiphoid process.

Speaker 2 (00:16:48):

Most patients with peptic ulcer disease or gastric ulcers or acid reflux have burning and pain exactly at that xiphoid process. It’s just, it’s described as like a knife stabbing in the area. So it could be none of the above completely unrelated to your laparotomy and really just internal area where your esophagus or your stomach is burnt by ulcers and has inflammation like esophagitis or gastritis, in which case endoscopy is the next step. And in doing the endoscopy they’ll actually examine the inner linings to see if it’s involved in inflammation or ulceration and some people have hernias there you can have what’s called a hiatal hernia where your stomach or some other organ travels up the chest, which it shouldn’t. That can cause pain. So see just one area of the body, right? Xiphoid process alone can have medical surgical problem, hernia, GI tract, et cetera. It’s usually not a bony problem, it’s usually not a nerve problem. So some of those other kind of diagnoses you can take off your list. So I hope that was helpful.

Speaker 2 (00:18:08):

So going back to differentiating the diagnosis for abdominal pain, we talked about activity. So activity induced pain is almost always musculoskeletal because of the muscle and hernias are considered part of the musculoskeletal system, whereas GI tract is almost never activity induced. So if you’re being told, okay, let’s get a colonoscopy or endoscopy, usually that’s not necessary as part of the workup, it’s just a comfort zone for the doctors because they’re uncomfortable with other diagnoses. So when do hernias cause abdominal pain? Good question. First of all, not all hernias cause abdominal pain or any pain. So just because you have a hernia doesn’t mean that that’s the cause of your pain, especially since hernias are so common. So it’s very good to have an open mind and not just repair any hernia and blame that as a cause of your pain. I see every year I see maybe four or five patients that had a hernia repair that absolutely did not need to be performed for treatment of some type of abdominal pain.

Speaker 2 (00:19:22):

And the abdominal pain was D separate, it was Crohn’s disease, it was prostatitis. They had some ovarian endometriosis let’s say. So they had the hernia repair, which they never needed and their underlying problem never got solved, but now they have a complication from their hernia repair. So it can happen every so often. I see a patient very complicated, can’t really figure out the pain. I’m like maybe it’s from the hernia, let’s fix the hernia and reevaluate. That’s okay. But if it’s glaringly not from the hernia and someone diagnoses hernia as part of the workup, then you have a hernia repair that you never really need and now you have a complication from that plus your underlying problem is not better, that’s not the best outcome that you would want. So that’s what we’re hoping that you don’t get, which is why I say every several months I bring this up, always get a second, maybe even a third opinion when you are told you need to have surgery, I don’t care if I’m the surgery recommending it or someone else is recommending it. I highly recommend that you see more than one doctor because you’re going to go into that surgery therefore with a better understanding of what your problem is, getting more of your questions answered and if there’s a conflict between the two surgeons, you can help figure out what that is so that you don’t necessarily undergo an unnecessary, unnecessary operation.

Speaker 2 (00:20:56):

All right, here’s another question I believe from the original question about the xiphoid. You mentioned hiatal hernia, traveling of the chest, what type of pain comes with this? I went to a doctor thinking this is what I had and was asked to get a CT scan which shows two ventral hernias with bowel. I think it is more than that as my pain is in the middle of the chest with spasms. So chest pain is almost never from ventral hernias. Ventral hernias are a hernias in the abdominal wall, usually in the front of the abdomen. It almost never causes chest pain. The pain that can be caused by chest pain, things that can cause chest pain of course to the heart, but it’s acid reflux and esophageal spasm esophagitis and anything else that competes with the esophagus for space. So a hiatal hernia is a hernia around the esophagus and stomach and either the stomach goes up into the chest or sometimes other organs go up in the chest and compete for space and that can cause chest pain or what we call retro sternal pain.

Speaker 2 (00:22:07):

So here’s your sternum pain behind that or sometimes we call it like acid reflux can cause the same problem but are spasms in that area. So the types of pain from hiatal hernia can include nothing or regurgitation of food. Acid reflux. Food reflux worse when you’re lying flat it can be a sharp stabbing pain into the chest. Some people get shortest of breath or anxiety, some people get hard palpitations even, but spams, the chest can occur or you can have an actual esophageal dysmotility where the esophagus does an empty very, very cord in a very coordinated way and because it’s doing that, it causes spasms and pain. So a good for gut surgeon can help you with that. Now here’s another question. I have acid reflux, gastroesophageal reflux disease, also known as GERD. Do you think a chiropractic should ever adjust this? Okay, so I have read about this because I thought it was interesting that a chiropractic would adjust for acid reflux. So the short answer is no. I do not believe a chiropractic should adjust for it. Acid reflux is either a functional or a mechanical problem if it’s functional because you just have abnormally loose esophagus sphincter and so every time you

Speaker 4 (00:23:44):

Eat the food goes beyond the esophagus, it reflexes back up. There’s no amount of spinal manipulation that can treat that. There are patients that have acid reflux because they have a hiatal hernia, their stomach is higher up in the chest than it should be, it should not be in the chest at all. And so there are physical therapists, nature paths and chiropractics that then massage the stomach down into the abdomen away from the chest and help relieve patients symptoms. It lasts hours today, it’s not a treatment at all and it is, how should I explain this? It’s like massaging and I don’t even know what kind of explanation I can give. You’re basically massaging the stomach down out of this hole but it doesn’t treat the hole and it doesn’t treat the symptoms more than the amount of time the stomach is down in the abdomen, which may be hours.

Speaker 4 (00:24:43):

So no, I do not believe a chiropractic should ever adjust for this. Sorry, next question. I have a physical therapy patient post-op hernia repair, Inguinal hernia repair with Mesh. Now the patient has terrible aching in the left lower quadrant worse than the hernia pain for the past five months. Have you seen this before? Yes, of course. So if it’s a left lower quadrant or left inguinal abdominal, sorry, left inguinal hernia repair and now they have left lower quadrant abdominal pain, it can be directly as a result of the hernia. If it’s on a opposite side of where the hernia is repaired, it’s probably not related to it, but depending on how the inguinal hernia was performed, laparoscopic or open with Mesh or without Mesh, you can get entrapment of bowel into the area. Scarring an adhesion of bowel to the area, a hernia within a hernia following up of the Mesh, tearing of the area, all of those or nerve damage, any of those can cause abdominal pain on the same side as the hernia repair. If the pain’s on the other side, then it’s unrelated to the hernia repair. Next question. Hello doctor, can you please touch on nursing women having hernia surgery? Could they delay it until they’ve finished breastfeeding? In fact, they should. We’ve discussed this on a couple of our different GYN episodes. So women that are nursing i e, they are breastfeeding, have the same kind of risk of hernias than any other person who’s who’s out there. In fact, the act of giving birth where your straining may exacerbate an underlying hernia. So we do not recommend that any hernia be repaired, electively during pregnancy,

Speaker 3 (00:26:44):

Shortly after pregnancy or anytime while breastfeeding. The reason for that is the hormonal changes that are in place are there to allow for your tissues to be very loose and accommodated for the increased abdominal for the pregnancy and those hormones linger on while you’re still breastfeeding. So your abdominal wall really doesn’t have the same capacity and resistance then it did before pregnancy. And so suturing on those tissues and closing those tissues will be an inadequate repair during the time of the hormonal levels. So the recommendations we make is that elective surgery be delayed for three months after the last day of breastfeeding. So go ahead and finish deliver your baby if you choose to breastfeed, continue doing that. Once you’re done with that, at least three months later you can then see a surgeon and consider hernia repair. Next question. I have had lower left abdominal pain and soreness for six months.

Speaker 3 (00:27:55):

Incredible amounts of gas and pain now radiates around my back and under the shoulder blade, left lower abdominal pain. Okay, colonoscopy, MRI. The pain increase are all negative. It hurts to bend over often feels like a contraction or squeezing next to the left of my belly button. CAT scan of the ab also negative. The back pain is better when I’m lying down. I also have pain now occurring in the inner thighs that come and go. Any ideas for me to look into with abdominal surgeon? I’m scheduled to see, sorry. Any ideas for me to look into with the abdominal surgeon I was scheduled to see next? I’ve had three laparoscopic operations for endometriosis and hysterectomy. I’ve also had pudendal neuraligia, but I have an asymptomatic. Oh my, you’ve had a lot going on. Okay, so if you have multiple laparoscopies, you’re definitely at risk for having a belly button hernia.

Speaker 3 (00:28:51):

It’s an incisional hernia at the belly button and that can cause back pain. It can cause pain to the left or right of the belly button and it usually doesn’t cause chest pain. So at the very least make sure you don’t have an incisional hernia at your belly button, which the CAT scan or MRI may show and may have been missed by the radiologist that that was actually there. So I want to have a second eye look at the MRI and CT scan to double check you don’t have a belly button hernia because if you had one from lap from if you had multiple laparoscopies, you’re definitely high at risk for having an incisional hernia at the belly button with endometriosis and hysterectomy. Okay, so you’ve had the hysterectomy, which means it’s unlikely that you have any his endometriosis related problems.

Speaker 3 (00:29:44):

Incredible amounts of gas can also be related to hernias. Hernias can cause bloating and then repairing of the hernias can repair all that. Then you also have groin pain going down the or pain that goes into your inner thighs. Inguinal hernias can cause inner thigh pain. There’s very few things that can cause inner thigh pain. Inguinal hernia is one of ’em. Spine disorder or sacroiliitis is another one and a hip disorder, all three of those can cause inner thigh pain. If it’s on both sides, it’s probably not your hip because most people don’t have equal equal amounts of hip injury on both sides. If it’s hernias, you can have hers on both sides. That’s possible. Both of them call it causing inner thigh pain. And then if it is sacroiliitis, that can also occur on both sides though often all of these can occur usually on one side.

Speaker 3 (00:30:38):

So any autoimmune disorder can cause the, sorry, there is an autoimmune disorder that causes sacroiliitis too. So it’s the SI joint in your back can be inflamed and then that can cause pain that radius to the groin and then the inner thigh. So those are all things to look into. They should re-review if you’re seeing the abdominal surgeon, they should re-review your imaging for belly button hernia. They should also examine you and review you for an inguinal hernia. They should examine your lower back for a sacroiliitis and do a hip exam to make sure you don’t have any hip problems. And let’s see, you bend over, you feel contracted squeezing left side of your blade button. That sounds like a belly hernia. Pain reading around the back, under the shoulder blade. That can be belly button. Yeah, for sure. I would love to hear if you can come back to us after your examination with your doctor.

Speaker 3 (00:31:39):

I would, I mean I’m so curious. I don’t even know you and I want to know what the trying solve this for you. So of course I’m free to look at your, I’m available to look at your images and review story if you want to do what’s what we call an online consult. But I would love it if you could come back on hernia attack and give us more information about what they thought was going on after you see your abdominal surgeon. I do have a small hernia, but they said it shouldn’t cause pain. Wrong umbilical hernias absolutely can cause pain. It can cause bloating, distension back pain, pain to the left or right of that belly button. And some people have pain that shoots down towards the, but not to the inner thigh. Yeah, they’re wrong. They’re wrong. Okay. See I don’t, I’ve never even seen you and I already kind of figured out a little bit. All right. What is your take

Speaker 2 (00:32:38):

On red light therapy used for scar tissue? The abdomen? Yeah, red light therapy is great. Ultrasonic therapy, red light therapy, the way it works is it reduces, it reduces inflammation and increases blood flow to the area and it’s considered a treatment to reduce scarring and scar formation. So as part of surgery or anything, you have this inflammatory response which then induces scarring. So if you can reduce that, it can reduce the scarring. So I’m a big fan of red light therapy. It’s hard to get, not everyone offers it. Let’s see, with regard to your observation that abdominal wall pain is precipitated by activity. Dr. Zoland in his book Deciphering Groin and Pelvic Pain observes on page 36 that the pain of the pubic plate disruption occurs not during the exertion but after often the warning after. Can you kindly comment on this and how to explain this phenomenon?

Speaker 2 (00:33:39):

Yes. So we did not discuss, I talked about hernias. We did not discuss muscle strains and kind of orthopedic injuries. So many patients with orthopedic injuries also have activity related pain. In some patients that activity is immediate. So the minute you have the activity, you have pain and others is delayed. So you, it’s almost like, how should I explain it? It’s like a soreness that you get after overuse of an injury in that you kind of work, work, work. And the actual tension or use of that muscle that is strained is not the problem. It’s as is in recovery that it gets more, that there’s more inflammation in the area and when you gain inflammation that causes the pain in the area. So in other words, this sports disruption, sports play disruption issue is really a muscle strain. The muscle let’s say is attached to the bone.

Speaker 2 (00:34:36):

It’s really not doing much and when you’re doing certain activities it can pull away from the bony attachment. Once it does that, it could be painful to do certain activities or it can get inflamed with certain activities. And when that inflammation peaks the next day, similar to why people are more in more pain after the one day or two days after a marathon, they don’t really feel it during the activity. It’s when the inflammation settles in, you get increased pressure in the area. I hope that was helpful. Okay, next question. I have extreme abdominal pain and pelvic pain has started getting very bad. Several months ago I had a ventral hernia repair done seven years ago, which was done using sutures because I’m an athlete and had very healthy muscles. I’m curious how big your ventral hernia was. I had an umbilical hernia repair and scar revision done two years

Speaker 5 (00:35:36):

After that. So where was your ventral hernia, if you can let me know about that, if it wasn’t an umbilical hernia. Let’s see. That surgery of the umbilical hernia did note, not note any use of Mesh either. I was able to run eight miles a day or less or more. Hold on. I was able to run eight miles a day or more, less than a year ago. And bicycle ride 10 miles several months ago with no issue. My abs had been very strong due to the amount of activity I do. I saw two acupuncturists for a tight jaw muscle and they both targeted my abdominals, which seemed to change my abdominal form. Now I can hardly bend over, walk, bend over a walk. My abdominal muscles feel like concrete and I’m having trouble relaxing and even breathing. I’m worried that Mesh was put in without my knowledge.

Speaker 5 (00:36:36):

Ventral light Mesh was listed on the surgical report but not listed as used. Is it possible to see this kind of Mesh on a scan? I had a CT scan but they didn’t see anything notable. Okay, great question. First of all, the opera report, there are two things to look for. If you think three things, if you think you had Mesh in you and you’re not sure, number one, read your surgical opera report dictate by your surgeon, that should say I put Mesh or I didn’t put Mesh in number one. Number two, there’s implant logs that are mandatory. So whenever any implant is placed in a patient that needs to be logged in with a lot number, that is usually not in your surgical op report, you have to specifically ask for that report from the hospital or surgery center where you had the operation.

Speaker 5 (00:37:29):

It’s oftentimes in the nursing notes or there’s a separate implant log form where they log in the implant. If that implant was logged in, then most likely you had that implant in you. Okay? And it’s, it’s uncommon, but it’s possible from human error that your opera report did not include the mention of the Mesh because of some force like they missed it or something for some reason. But that would be uncommon if you could also see what you were built for. Look at your billing invoice. Were you billed for Mesh or were you not billed for Mesh? So those are three ways to figure it out. The offer report by the surgeon, the nursing or hospital or surgery center implant log and your billed to see if you were billed separately for the Mesh. Now CT scanner will often not show the Mesh very clearly because it’s gray looking usually and your muscles also gray. So gray on gray looks exactly

Speaker 2 (00:38:34):

The same and so it’s hard to tell. What you can do is get an MRI. An MRI will show if there’s any permanent suture or permanent Mesh in that area pretty reliably you would need a non-contrast MRI ordered of that area of your body just to identify whether you have Mesh in you or not. Definitively. I’ve had people coming to me asking, saying they’ve been sick every ever since they’ve had Mesh in them. And I’m like, you don’t have Mesh? Yes I do. I know I had Mesh in me. My surgeon told me they have Mesh them. I’m like, but your operative report doesn’t say it. And they log implant log doesn’t say it. And sometimes these were like 25 years ago, 35 years ago where they claimed they had the surgery and so I would get an MRI and of course also no Mesh. And in one case I even called the surgeon who was retired and he said this was a tummy tuck. He’s like, oh, I’ve used maybe two or three patients where I’ve had Mesh in them for tummy tuck. She was definitely not one of ’em. So no, I can guarantee I did not put Mesh. So implant log, opera report, nursing notes, billing, and then MRI.

Speaker 2 (00:39:53):

Thank you. That was a terrific response to explain Dr. Zoland’s observation. Oh, you’re welcome. All right, we’re caught up with some of your questions. So the next is, when do hernias cause abdominal pain? Everyone’s variable, so you can’t say like last patient who could have the question, oh, you have belly button hernia- that can’t cause your pain. That’s not correct. In some people it may and others it may not. You can have small hernias with an itsy bitsy piece of fat in there, horrible pain, especially in athletes because they really know their body very well. Or you can have a huge hernia with tons of bowel in it and no pain, and some combination thereof. So it’s unclear which hernias and which types of hernias and which size hernias cause pain, but they do cause pain. Not all the time. That’s kind of the area where there’s kind of shadiness in there.

Speaker 2 (00:41:00):

So when do hernias cause abdominal pain? Usually it’s if something is trapped in it like bowel or even fat. And that’s often when the neck of the hernia, the hole is smaller than the content that’s trapped in it. So if I give you a ring that’s smaller than your finger, that’s going to trap the blood flow there and cause you pain, you can never wear a ring that’s smaller than your finger size. It’s just uncomfortable or you’ll lose your finger. So the same thing is true for a hernia. The amount of content that goes into the hernia defect, if it’s tighter and more than the actual with of the neck of it, then that is a problem and can cause pain. The other reason why hernias can cause pain is if they’re actively trying to tear. So if you’ve had surgery and you have pain, often it’s because the muscles are trying to pull away where the surgery was. That’s why we moved away from tissue repairs both for ventral hernias and for inguinal hernias and more towards Mesh based hernias. Because oftentimes what’s happening is you get chronic pain because you’re constantly trying to tear at the tissue levels and once you do tear and you get another hernia, then that hernia will be even more difficult to repair because now the hole is bigger and you have less tissue that’s healthy to close it. So hernias cause pain if something’s being pinched or if it’s trying to tear away from the suture line.

Speaker 2 (00:42:32):

Let’s see, we got another question. I’ve had several abdominal for endometriosis and uterine suspension. Perforated diverticulitis, perforated diverticulitis with abdominal abscess ileostomy resection four ventral hernias, three with bowel and now two more ventral hernias. I have been turned down by two surgeons already just to be seen. My colon surgeon wants me to consider an abdominal abdominal reconstruction and see a hernia specialist. Can you discuss abdominal wall reconstruction? Oh absolutely. I would love to. That’s why I’m here. So abdominal wall reconstruction typically refers to a hernia repair that requires more than just closing the hole or patching the hole. You need to reconstruct it because it’s a complicated situation. Either the holes are too big, too wide, multiple or in weird areas like the side or the flank and so on. And so your surgeon is correct, it should not be addressed by your average general surgeon.

Speaker 2 (00:43:38):

Most of them are not skilled and don’t understand the intricacies almost tried to sneeze there. Most of them don’t understand the intricacies of how to perform these and therefore to perform it well so you don’t have a problem or complication from the operation. So there are multiple surgeons. I have personally interviewed many of them because there’s ones who I feel are very skilled on hernia talk live. And so you can kind of seek their consultations for abdominal law reconstruction. Of course I also do abdominal law reconstruction. So what it involves is really reconstructing and rearranging your anatomy a little bit. So the typical anatomy is the rectus muscles in the middle and then the three sets of obliques on the side. If you have a lot of holes and sounds like you do with ball and them, et cetera, some of those holes can be closed, but some of them may not be just able to be closed because it’s too wide. So you have to shift the tissues and the muscles against each other to be able to overcome the tension of just closing a very wide hole. And that’s part of the reconstruction terms that people may use is TAR, which it stands for T A R Transverses abdominal release eTEP, which we discussed two weeks ago.

Speaker 2 (00:45:05):

Tap R tap, these are all different terms. They use Rive Stoppa. These are posterior component separation and tear component separation. These are all various techniques that are used. Now before you go into any type of surgery, you must make sure you are not overweight and definitely not morbidly obese because that is a disaster scenario where you’re needing surgery, but your weight is to the point where it’s adding a lot of tension to the repair and they either can’t do a good repair or if they do a good repair, it’s under tension because there’s all this other abdominal fat that’s pulling on it and then the it will recur. And now you have a failed abdominal wall reconstruction, which you definitely don’t want to have and you’ll need another operation, which is an even smaller range of surgeons that are able to do that. So my suggestion is do your best to reduce your risk factors for surgery. So no nicotine, make sure your diabetes is well controlled if you have it. No cough, no constipation or straining. No, you’re a female so you can’t have cross issues and then not morbidly obese. And then definitely go seek an abdominal reconstruction surgeon. The recovery is often long unless it can be done robotically in which the recovery tends to be short. So those are actually kind of fun to do. And recreating the abdomen is really fun because you end up really reconstructing to a flatter look less pain and so on. I love it.

Speaker 2 (00:46:49):

Next question, I’m dying to hear about the boy whose pain was relieved by the Oh, the hot bath patient! Yes. Thanks for reminding me. Okay, you know what causes abdominal pain that’s relieved by sitting in a hot tub or a hot bath? Marijuana, use of marijuana. This kid was using marijuana. I think his friends were slipping it to him. Of course we’re in California, this was a while ago. So marijuana, some people get a bad reaction to marijuana. That reaction is abdominal pain. And classically that abdominal pain gets better if you sit in a hot bath, we think it has to do with the blood flow to the intestines and somehow the marijuana either reduces the blood flow or causes spasm of the arteries and so on because he wasn’t losing weight, actually, he was a chubby kid, so it’s not like he was in so much pain that he wasn’t able to eat. He had a full workup, endoscopy, colonoscopy, tons of cat scans, angiograms to look specifically at the blood vessels to see if they had any disease. Totally normal. I don’t believe he had surgery, so that’s a good thing because he didn’t need it.

Speaker 2 (00:48:20):

But unfortunately he’s one of those people that has an allergy or a reaction to the use of marijuana. And so that was a medical cause for what was considered to be a surgical problem, which is abdominal pain with meals. So I love it. Thanks. It would be horrible if I went through this whole hernia talk live scenario and forgot to give you the answer. Kept ya hangin’. Okay, why don’t doctors diagnose hernia as a cause of my abdominal pain or my pelvic pain? That’s a great answer. I think similar to the question that was asked a while ago. Doctors discount how many symptoms you can get from a hernia. You can get bloating, back pain, nausea, pain with bending and sitting, a lot of symptoms that you can get from a hernia that people don’t usually associate with. They think you have to have pain exactly at the hernia.

Speaker 2 (00:49:27):

So women can have pain with intercourse, pain in the groin with in their pelvis, with their periods, and of course they’ll be sent to a gynecologist for that, not to a hernia surgeon, but the hernia is the cause of their pain. Men can have testicular pain. I see a lot of men with testicular pain. Now often that’s not the cause not caused by a hernia, but it can be. And so if you can’t figure out why you have testicular pain, let’s look at a hernia as a possibility of your pain. So the problem is that hernias are not well taught. It’s very common. It’s kind of like considered it’s just a hernia. So the medical school curriculum glances over it even though it’s one of the most common diagnoses. Medical doctors, family medicine, gynecology, gastroenterology, even general surgery, urology, they discuss it but they don’t, if anything they discuss how to fix it but how to really diagnose it and feel for it.

Speaker 2 (00:50:26):

They’re not very good at that. So surgeons and doctors are very surprised. Oh, you can get bloating from a hernia? Oh, I didn’t know you can get nausea from a hernia. Oh it can cause back pain? I didn’t know that. So it’s one of those things where it’s just not appreciated and not every patient is textbook and so it’s very important that that doctors are open-minded because not every patient’s the same. Next question, have you heard of placental cell allograft stem cells or other biologic use to promote healing after abdominal wall reconstructions or even after regular hernia surgeries to promote healing and prevent a adherence? Great question. Yes and no. So we don’t actively use stem cells for anything related to the hernias, although I’m sure there’s research ongoing where we’re hoping that an injection into an area will either prevent a hernia or help heal a hernia so that the areas where the collagen, let’s say it’s mismatched you have, maybe it’ll increase the level of mature collagen in the area or MMPs and other proteases in the area will can be altered with injection of these stem cells. So there is very little, but there is research in looking at that. In terms of injecting things to promote healing and prevent adhesions. There are synthetic, I don’t want to call ’em stem cell, they’re like amniotic cell sheets, very expensive that you can place in certain areas to promote healing. Very expensive. It’s question whether they really work, but there are amniotic sheets, cell sheets that are commercially available that you can use to help reduce scarring and scar formation and promote healing in the area. So yes, there is that.

Speaker 2 (00:52:35):

Look at all your questions. Let’s see, I did not use marijuana, but I have chronic inguinal pain without hernias, but maybe training that is relieved temporarily by the use of a hot heating pad for several hours. What are your thoughts on this? So he just understand heating pad versus cold packs. If you have inflammation in the area, that inflammation is from a hernia, from muscles tear, then cold packs, ice packs work the best. And the reason for that is it really kind of reduces the inflammation in the area, reduces blood flow to the area, less pain and lasts a very long time. If you have a muscle spasm in the area, not a muscle strain or a sports hernia, but a muscle spasm, then heat packs can increase blood flow to reduce the spasm. Kind of like what’s the right term, kind of soften up the muscle a little bit and reduce the spasm. So heat packs work for muscle spasm and cold packs work for inflammation. So I would try cold packs or ice packs for your chronic groin pain, maybe due to hernia or muscle strain and see if that actually gives you more relief because if you’re also taking let’s say ale or which is naproxen or ibuprofen, which is Advil, which are both anti-inflammatories, then ice pack would be a nice adjunct cause that’s also a very strong anti-inflammatory.

Speaker 2 (00:54:15):

Next question, can you mention what type of CT scans best to diagnose a hernia as just laying down may not show? Excellent question. I had a whole section I think on radiology. Yeah, I had a whole hernia attack live on radiology alone and what to order and how to order. So I highly suggest you go to that episode, which was I think within the past six months. CT scan is best for eventual hernias to abdominal wall umbilical, all those and it can be ordered with oral contrast, which means you drink the contrast cause at least that’ll differentiate intestine from everything else. And on the report it’s a request it just say with Valsalva, which is a bare down view. So you add Valsalva, it’s often not a good test. So I prefer ultrasound or MRI for those. And both of those are dynamic or tests with Valsalva.

Speaker 2 (00:55:18):

So hernia, if you really want to do a really good job to look at hernias, especially occult hernia, you want to use things with Valsalva or bear down views. But if it’s a big hernia and you just want the imaging to demonstrate the what’s going on there and not necessarily actually diagnose the hernia, then a CT scan just flat is perfectly fine. Next question, a muscle spasm and the abdomen comes and goes and inflammation all is all the time usually. No, not necessarily. So inflammation can occur because things are trying to struggle to go into the hole for example, or trying to pull things apart, whereas at rest you may not have inflammation. So inflammation can come and go as well as muscle spasm is pain. Next question, is pain surrounding an area of nerve damage? A common thing? What specifically may cause this? So if there’s an area of nerve that’s damaged, whether it’s by surgery or trauma, there’s really no other reason for it to be damaged, then the pain would be along the length of the nerve.

Speaker 2 (00:56:35):

So the nerve starts, the spine actually starts, the brain goes down the spine comes out of the spine towards whatever area. So the groin for example, wraps around the back and then towards the groin and then maybe the inner thigh. So you would get pain along the length of the nerve, but the pains, you should not have pain surrounding the area unless there’s another cause for pain in the area. So let’s say for example, you have nerve damage from a hernia repair because the nerve is entrapped or was accidentally cut or injured as part of your hernia repair, that’s fine. You can also have pain from the actual hernia repair in the Mesh, let’s say in that area, which is separate and maybe contributing to why the nerve was damaged. However, if you just have isolated nerve damage and nothing else, then the only pain you should have would be along the nerve itself.

Speaker 2 (00:57:34):

You guys are asking great questions. We’ve got a couple more minutes, so let’s go through, let’s see, one more question. Can I have hernia pain and some other ailment causing my abdominal pain? Yes. Kind of alluded that earlier. So a good clinician should be able to identify the hernia and figure out what percentage or component of your pain is due to the hernia and then what component or percentage of the pain is due to something else. For example, I had a patient, I think this was yesterday, it was a telehealth and I was trying to kind of really figure out for him what part of his pain is hernia pain and what part of his pain is pudendal pain. So because his pudendal pain, thank God, is much better with injections. And pudendal Neuralgia, he had perineal pain, and kind anal pain, but the groin, but the bloating that he had, the nausea, the groin pain, the testicular pain, the pain wrapping around the back, that was all inguinal hernia related pain.

Speaker 2 (00:58:42):

So you can have multiple problems at one time, especially with hernias because hernias are so common and many of them are so asymptomatic or minimally symptomatic that it’s really important to understand that you can have many, many other types of pain and also have a hernia, but it’s unrelated to the fact that you have a hernia. It’s one of those things where you really need to just have a great surgeon, help figure it out because the that’s where the whole, I don’t know, that’s where the fun of it is. How much of this is what, and then you can do a nerve block or a certain type of medication or change certain activities and then be able to figure out what causes which pain. All right. That time has come everyone. Thanks for joining me. That was a fun one. It was like a rapid fire. I like that rapid fire hernia talk. I should change the name to it. So that was fun. We should do it again. We will do it again next week. Thanks for joining me. Everyone follow me on Twitter and Instagram at hernia doc on Facebook at Dr. Towfigh. I will promise I will post last week and this week’s episodes on YouTube. So follow me on that channel and just watch it.