CT Imaging for Epigastric Hernia
For evaluating an epigastric hernia, CT without contrast is generally sufficient for diagnosis, though CT with IV contrast provides superior visualization if complications such as strangulation or ischemia are suspected. 1, 2
Imaging Approach for Epigastric Hernia
Standard Diagnostic Protocol
CT scan is the gold standard for diagnosing abdominal wall hernias, including epigastric hernias, with high sensitivity for detecting hernial defects and their contents 1, 2
Non-contrast CT can identify the hernia defect and herniated contents in uncomplicated cases, making it an appropriate initial imaging choice 1
Point-of-care ultrasound (POCUS) is also useful for evaluating suspected external hernias like epigastric hernias and may be considered as a first-line modality in some settings 1
When to Add IV Contrast
CT with IV contrast is strongly recommended when:
Complications are suspected, including bowel strangulation, ischemia, or obstruction 2, 3
Vascular assessment is needed to evaluate mesenteric vessel engorgement, which indicates potential strangulation 2, 3
Signs of intestinal compromise are present, such as bowel wall thickening, abnormal enhancement, or mesenteric infiltrates 3
Key CT Findings to Identify
Diagnostic features of hernias on CT include:
Discontinuity of the abdominal wall fascia at the hernia site 1
Herniated abdominal contents (typically preperitoneal fat or bowel loops) protruding through the fascial defect 4, 5
Cluster of bowel segments at an abnormal anatomic location if bowel is herniated 4, 3
Warning signs of strangulation requiring urgent intervention:
Engorged and stretched mesenteric vessels with crowding and convergence at the hernial orifice 4, 3
Bowel wall thickening with abnormal enhancement pattern 3
Mesenteric infiltrates and localized fluid surrounding the hernia 3
Absence of bowel wall contrast enhancement, indicating ischemia 2
Clinical Context Matters
Important distinction: The provided guidelines primarily address internal hernias (diaphragmatic, hiatal, foramen of Winslow) rather than epigastric hernias specifically 1, 2. However, the imaging principles apply similarly:
Epigastric hernias are external abdominal wall hernias occurring through the linea alba between the xiphoid and umbilicus 5
They can present with epigastric pain and may be confused with other causes of epigastric discomfort 6, 7
CT is valuable for confirming the diagnosis when clinical examination is equivocal or when complications are suspected 7
Common Pitfalls to Avoid
Do not assume all epigastric pain is from the hernia itself—consider other serious conditions like peptic ulcer disease, gastric pathology, or cardiac causes 8
Do not delay imaging if strangulation is suspected—early diagnosis reduces morbidity and mortality 4, 3
Do not rely solely on clinical examination for epigastric hernias, as they can be difficult to palpate, especially in obese patients 5, 7
Recognize that normal findings on non-contrast CT do not exclude early strangulation—if clinical suspicion remains high, contrast-enhanced CT provides better assessment of bowel viability 2, 3