Hernia and Inguinal Hernia

Doctor, I have a lump in my groin/ on my abdomen for 2 weeks. It is bigger when I stand up or doing my gardening, but disappears when I go to sleep or lie down. It is not painful but I feel heavy in my groin. Recently, it became slightly bigger and giving me some dull ache in it. Am I having a groin hernia?

 What is a hernia?

  • A hernia is an abnormal outpouching of an organ out of its containing cavity via a natural or acquired weakness of the cavity wall. It can happen in many locations but the commonly seen hernias are in the tummy (abdomen) and groin.
  • The common abdominal hernias are inguinal, femoral, hiatal, incisional, umbilical and paraumbilical hernia. It commonly presents as a lump or swelling at your abdomen or groin.
  • The lump can often be pushed back in or disappears when you lie down. Coughing or straining may make the lump appear. However, in severe cases, the lump may not be pushed in and may be associated with a lot of pain.


hernia location

What is an inguinal hernia?

It is a hernia that occurs in the groin. Fatty tissue or part of the bowel are commonly involved, pokes through the groin at the top of our inner thigh, forming a lump/swelling. The common two types of inguinal hernia are:-

  • Indirect inguinal hernia – caused by a defect in the abdominal wall that is present since birth, but may present later in life.
  • Direct inguinal hernia – caused by a weakness in the abdominal wall that develops over time


Who is more likely to develop inguinal hernia?

  • Male – male has ~25% lifetime risk of developing inguinal hernia but female has only ~2% lifetime risk.
  • Age – inguinal hernia can happen at any age. Premature infant has higher chance of developing indirect hernia. Indirect hernia tends to presents before 30 years old whereas direct hernia commonly presents after 40 years old.
  • Smokers
  • People with family history of hernias


What are the signs and symptoms of inguinal hernia?

The first sign of an inguinal hernia is a small bulge on one, or sometimes both,   groin(s). The bulge may increase in size over time and usually disappears when lying down. Other signs and symptoms can include:-

  • discomfort or pain in the groin – especially when straining, lifting, coughing, or exercising – that improves when resting
  • weakness, heaviness, burning, or aching in the groin
  • a swollen or an enlarged scrotum in men or boys – inguinal hernias may slide in and out into the scrotum.

What are the complications of inguinal hernia?

Inguinal hernia can cause the following complications:-

  • Incarceration. The hernia content became stucked in the groin or the scrotum. This can cause discomfort or pain then leads to more severe complications such as bowel obstruction or strangulation.
  • Obstruction. The part of bowel that is kinked and blocked. It is life-threatening and requires urgent surgery.
  • Strangulation. The blood supply to the incarcerated herniated bowel becomes kinked, twisted or blocked, causing the bowel to die. It is life-threatening and requires immediate surgery. Bowel resection may be required.


incarcerated and strangulated hernia

Dangerous signs that one should seek immediate care

  • Extreme pain or redness in the area of the swelling in the groin
  • Sudden pain that worsens quickly and does not go away
  • Cannot pass bowel movement or gas
  • Nauseated, vomiting, fever

How are inguinal hernias diagnosed?

Doctor can diagnose an inguinal hernia by medical history taking and physical examination. He may get further imaging tests if needed, such as X-Ray, ultrasound or CT scan of the abdomen.

How are inguinal hernias treated?


Surgical repair is the only effective hernia treatment, especially for people with hernias that cause symptoms. It prevents incarceration, obstruction and strangulation. Emergent or immediate surgery is needed for incarcerated or strangulated hernias.

A synthetic mesh is commonly used in the hernia repair to strengthen the abdominal wall and to reduce hernia recurrence.

Recovery after the surgery is usually fast. However, it depends on the size of the hernia, the surgical technique, the age and the health of the patient. There are two main inguinal hernia surgical repair approaches:-

hernia repair pic

Laparoscopic Inguinal Hernia Repair

This procedure is done under general anaesthesia. The surgeon makes several tiny cuts, each about 0.3 – 1 cm, on the abdomen, and inserts a laparoscope – a thin tube with tiny video camera attached that sends a magnified closed up image from inside the body to a monitor. While watching the monitor, the surgeon uses the small thin instruments carefully repair the hernia/defect with a synthetic mesh. The patient who had this procedure commonly recovers very soon and able to return to work much faster because of lesser pain and smaller wounds than convention open hernia repair.

Open Inguinal Hernia Repair

This procedure can be done under general anaesthesia, spinal anaesthesia (half body) or local anaesthesia (local block). The surgeon makes an incision in the groin, about 4 – 10 cm (depending on the hernia’s size), separates the muscle and fascia layers, repairs the hernia, and reinforces the abdominal wall with stitches and a synthetic mesh to provide additional support.

Open hernioplasty of both inguinal (arrow indicates the incision)
Open hernioplasty of both inguinal (arrow indicates the incision)

Can inguinal hernia be prevented?

People cannot prevent the weakness of the abdominal wall that causes indirect inguinal hernia. However, people may be able to prevent direct inguinal hernia by maintaining a healthy lifestyle and not smoking.

People can prevent inguinal hernias worsening or recurring after surgery by

  • avoiding lifting heavy objects

  • using the legs, not the back, when lifting objects

  • avoid constipation and straining during bowel movements

  • maintain a healthy weight

  • quit smoking

Peptic Ulcer Disease and Helicobacter pylori

What is a Peptic Ulcer?

A peptic ulcer is a sore or a wound in the lining of our stomach and duodenum. Duodenum is the first part of our small intestine.


What causes peptic ulcer?

  • The natural protective mechanism of our stomach protects us from ulcer. It consists of our strong intestinal lining, our intestine’s acid clearance ability and its acid production rate control. The imbalance of the mechanism may cause a break in the intestinal lining and becomes an ulcer later.
  • Causes of peptic ulcer include:
    • Helicobacter pylori ( pylori) infection
    • Medications – Non-steroidal anti-inflammatory drugs (NSAIDs), a class of pain killers that includes aspirin, ibuprofen, diclofenac and etc.
    • Taking steroids for other medical illness
  • Risk factors of getting peptic ulcer include:
    • Smoking
    • Drinking too much alcohol
    • Patient who had previous peptic ulcer
    • Stressful lifestyle
    • Certain pre-existing illness – MEN syndrome, Zollinger Ellison syndrome, cancer

What other problems can peptic ulcer disease cause?

Peptic ulcer causes many problems including:-

  • bleeding from the ulcer due to a broken blood vessel
  • a hole in the stomach wall or small bowel
  • a blockade that can stop the food from moving from stomach into small bowel

 What are the symptoms of peptic ulcer disease?

The most common symptom of a peptic ulcer is burning pain in the upper abdomen, which can range from mild to severe. In severe cases, the pain may disturb your sleep and wake you up at night.

Other common symptoms include:

  • Loss of appetite
  • Nausea
  • Bloody or black tarry stool
  • Unexplained weight loss
  • Indigestion, feeling bloated or gaseous
  • Vomiting that has coffee ground material or blood
  • Chest pain

How is peptic ulcer diagnosed?

The doctor can make the diagnosis based on medical history, physical examination, laboratory tests, Upper GI Endoscopy and/or other tests.


Upper GI Endoscopy (OGDS)

  • For your comfort, this procedure may be done under adequate sedation while you are lying down on your side
  • The doctor inserts a thin tube with camera down your throat into the stomach and duodenum to examine the area for ulcer.
  • It produces a direct magnified vision of the intestinal lining that allows doctor to perform careful and detail inspection. It also allows the doctor to give treatment and to take tissue biopsy if needed.

The other tests are indirect examination of peptic ulcer, such as Barium meal and Upper GI Series, CT scan, blood tests or Urea Breath Test for H. pylori. These tests are indirect and have their pros and cons.

How is peptic ulcer treated?

  • Your doctor will decide the best treatment based on the cause of the peptic ulcer. The following medications are commonly used, either individually or in combination:-
    • histamine receptor blocker
    • proton pump inhibitor
    • antibiotics to treat pylori infection
  • The duration of treatment depends on the severity and cause of the peptic ulcer.
  • Your doctor may also advise you to reduce or replace certain medications that may have caused the peptic ulcer. Please check with your doctor about which medications may cause peptic ulcer.
  • Drinking alcohol and smoking slows down the healing of peptic ulcer. If you smoke, you should consider quitting. If you drink, you should drink less or consider quitting too.

Can peptic ulcer come back?

Yes, if the risk or causative factors remains, your peptic ulcer is more likely to come back.

How can I prevent peptic ulcer disease?

It can be prevented by avoiding the causative or risk factors mentioned earlier.

Maintaining a healthy lifestyle trough balance diet rich in fruits and vegetables may help to prevent peptic ulcer.


Helicobacter pylori seen under the electron microscope

 What is Helicobacter pylori (H. pylori)?

  • It is a small, spiral, bacteria with tails. It lives or infects the stomach, lives under the mucous layer but above the stomach wall lining. It has the ability to irritate the stomach wall, produces toxin that will weaken the stomach lining and leads to ulcer formation.
  • pylori infection are associated with unclean or contaminated food/water intake.
  • Its presence can be detected with many tests but all have its pro and cons. The commonly used tests are:-
    • Blood test
    • Urea breath test
    • Rapid Urease Test on tissue biopsy during endoscopy
  • pylori infection can be treated with antibiotics and proton pump inhibitor. Re-infection can happen but it can be treated again with medications.
  • To prevent pylori infection, you should:-
    • Wash your hands well after using the bathroom before eating
    • Wash and cook your food properly
    • Drink water from a clean and safe source