How do I rule out an umbilical hernia?

Ruling Out Umbilical Hernia

To rule out an umbilical hernia, perform a focused physical examination looking for a palpable fascial defect at the umbilicus with or without a visible bulge, assess reducibility by attempting gentle manual reduction, and if the diagnosis remains uncertain or complications are suspected, obtain ultrasound or CT imaging. 1

Physical Examination Technique

The diagnosis of umbilical hernia is primarily clinical and relies on systematic physical examination:

• Inspect the umbilical area with the patient standing and supine, looking for a visible bulge or protrusion at or near the umbilicus that may increase with coughing, straining, or Valsalva maneuver 1
• Palpate the umbilical ring to identify a fascial defect—you should be able to feel the edges of the defect and estimate its size (typically ranging from <1 cm to several centimeters) 2, 3
• Assess reducibility by attempting gentle manual reduction of any protruding contents back into the abdominal cavity—a reducible hernia will easily return with gentle pressure, while an irreducible hernia suggests incarceration 1, 4
• Examine with the patient performing Valsalva or coughing to increase intra-abdominal pressure and make subtle hernias more apparent 1

Critical Red Flags Requiring Urgent Evaluation

If any of the following are present, the hernia is complicated and requires immediate surgical consultation:

• Severe, constant pain at the hernia site (suggests incarceration or strangulation) 1
• Inability to reduce the hernia manually (indicates incarceration) 1
• Erythema, skin discoloration, or pressure necrosis over the hernia (suggests compromised blood supply) 1
• Nausea, vomiting, or inability to pass gas (indicates bowel obstruction) 1
• Fever or systemic signs of infection (suggests strangulation with bowel necrosis) 1

When Imaging Is Indicated

Imaging is not routinely needed for simple, reducible umbilical hernias with clear clinical findings, but should be obtained in specific circumstances:

• Ultrasound is useful when the diagnosis is unclear on physical examination, to assess hernia contents and confirm reducibility 1
• CT scan with IV contrast is recommended when complications are suspected (irreducibility, signs of strangulation), when the diagnosis is uncertain, or to evaluate for alternative pathology 1
• Plain radiographs (anteroposterior and lateral) should be obtained if bowel obstruction is suspected, looking for dilated bowel loops or free air 1

Laboratory Testing

No routine laboratory work is needed for simple umbilical hernias, but if complications are suspected:

• Complete blood count to assess for leukocytosis indicating infection or ischemia 1
• Inflammatory markers (CRP, procalcitonin, lactate) to evaluate severity of complications 1
• Basic metabolic panel to check for electrolyte abnormalities and renal function 1

Common Pitfalls to Avoid

• Do not delay evaluation of irreducible hernias—any hernia that cannot be reduced requires urgent surgical consultation regardless of other symptoms 1
• Do not assume small hernias are benign—while incarceration and strangulation are uncommon in umbilical hernias, they can occur and require immediate intervention 5, 4
• Do not rely solely on patient-reported reducibility—always attempt manual reduction yourself during the physical examination 1
• Do not miss associated symptoms of bowel obstruction—specifically ask about nausea, vomiting, constipation, and inability to pass gas 1