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Herbal medicine (also Herbalism) is the study of the botany and use of medicinal plants. Plants have been the basis for medical treatments through much of human history, and such traditional medicine is still widely practiced today.^[1] Modern medicine makes use of many plant-derived compounds as the basis for evidence-based pharmaceutical drugs. Although herbalism may apply modern standards of effectiveness testing to herbs and medicines derived from natural sources, few high-quality clinical trials and standards for purity or dosage exist.^[2] The scope of herbal medicine is sometimes extended to include fungal and bee products, as well as minerals, shells and certain animal parts.

Herbal medicine is also called phytomedicine or phytotherapy.^[3]Paraherbalism^[4] describes alternative and pseudoscientific practices of using unrefined plant or animal extracts as unproven medicines or health-promoting agents.^[1][2][4][5] Paraherbalism differs from plant-derived medicines in standard pharmacology because it does not isolate or standardize biologically active compounds, but rather relies on the belief that preserving various substances from a given source with less processing is safer or more effective – for which there is no evidence.^[4] Herbal dietary supplements most often fall under the phytotherapy category.^[5]

• 2Modern herbal medicine
• 4Traditional systems

History[edit]

Archaeological evidence indicates that the use of medicinal plants dates back to the Paleolithic age, approximately 60,000 years ago. Written evidence of herbal remedies dates back over 5,000 years to the Sumerians, who compiled lists of plants. Some ancient cultures wrote about plants and their medical uses in books called herbals. In ancient Egypt, herbs are mentioned in Egyptian medical papyri, depicted in tomb illustrations, or on rare occasions found in medical jars containing trace amounts of herbs.^[6] Among the oldest, lengthiest, and most important medical papyri of ancient Egypt, the Ebers Papyrus dates from about 1550 BC, and covers more than 700 compounds, mainly of plant origin.^[7] The earliest known Greek herbals came from Theophrastus of Eresos who, in the 4th century BC, wrote in GreekHistoria Plantarum, from Diocles of Carystus who wrote during the 3rd century BC, and from Krateuas who wrote in the 1st century BC. Only a few fragments of these works have survived intact, but from what remains, scholars noted overlap with the Egyptian herbals.^[8] Seeds likely used for herbalism were found in archaeological sites of Bronze Age China dating from the Shang Dynasty^[9] (c. 1600–1046 BC). Over a hundred of the 224 compounds mentioned in the Huangdi Neijing, an early Chinese medical text, are herbs.^[10] Herbs also commonly featured in the traditional medicine of ancient India, where the principal treatment for diseases was diet.^[11]De Materia Medica, originally written in Greek by Pedanius Dioscorides (c. 40–90 AD) of Anazarbus, Cilicia, a Greek physician, pharmacologist and botanist, is one example of herbal writing which was used for 1500 years until the 1600s.^[12]

Modern herbal medicine[edit]

The World Health Organization (WHO) estimates that 80 percent of the population of some Asian and African countries presently use herbal medicine for some aspect of primary health care.^[13] Pharmaceuticals are prohibitively expensive for most of the world's population, half of whom lived on less than $2 U.S. per day in 2002.^[14] In comparison, herbal medicines can be grown from seed or gathered from nature for little or no cost.

Many of the pharmaceuticals currently available to physicians have a long history of use as herbal remedies, including opium, aspirin, digitalis, and quinine. According to the World Health Organization, approximately 25% of modern drugs used in the United States have been derived from plants.^[13] At least 7,000 medical compounds in the modern pharmacopoeia are derived from plants.^[15] Among the 120 active compounds currently isolated from the higher plants and widely used in modern medicine today, 80% show a positive correlation between their modern therapeutic use and the traditional use of the plants from which they are derived.^[16]

Clinical tests[edit]

In a 2010 global survey of the most common 1000 plant-derived compounds, 156 had clinical trials published.^[17] Preclinical studies (cell culture and animal studies) were reported for about one-half of the plant products, while 120 (12%) of the plants evaluated – although available in the Western market – had no rigorous studies of their properties, and five were toxic or allergenic, a finding that led the authors to conclude 'their use ought to be discouraged or forbidden.'^[17] Nine plants evaluated in human clinical research included Althaea officinalis (marshmallow), Calendula officinalis (marigold), Centella asiatica (centella), Echinacea purpurea (echinacea), Passiflora incarnata (passionflower), Punica granatum (pomegranate), Vaccinium macrocarpon (cranberry), Vaccinium myrtillus (bilberry), and Valeriana officinalis (valerian), although generally there were inconsistent, often negative results, and the studies were of low quality.^[17]

In 2015, the Australian Government's Department of Health published the results of a review of alternative therapies that sought to determine if any were suitable for being covered by health insurance; Herbalism was one of 17 topics evaluated for which no clear evidence of effectiveness was found.^[18] Establishing guidelines to assess safety and efficacy of herbal products, the European Medicines Agency provides criteria for evaluating and grading the quality of clinical research in preparing monographs about herbal products.^[19] In the United States, the National Center for Complementary and Integrative Health of the National Institutes of Health funds clinical trials on herbal compounds, provides fact sheets evaluating the safety, potential effectiveness and side effects of many plant sources,^[20] and maintains a registry of clinical research conducted on herbal products.^[21]

According to Cancer Research UK as of 2015, 'there is currently no strong evidence from studies in people that herbal remedies can treat, prevent or cure cancer'.^[3]

Prevalence of use[edit]

The use of herbal remedies is more prevalent in patients with chronic diseases such as cancer, diabetes, asthma and end-stage renal disease.^[22][23][24] Multiple factors such as gender, age, ethnicity, education and social class are also shown to have association with prevalence of herbal remedies use.^[25]

A survey released in May 2004 by the National Center for Complementary and Integrative Health focused on who used complementary and alternative medicines (CAM), what was used, and why it was used. The survey was limited to adults, aged 18 years and over during 2002, living in the United States. According to this survey, herbal therapy, or use of natural products other than vitamins and minerals, was the most commonly used CAM therapy (18.9%) when all use of prayer was excluded.^[26][27]

Herbal remedies are very common in Europe. In Germany, herbal medications are dispensed by apothecaries (e.g., Apotheke). Prescription drugs are sold alongside essential oils, herbal extracts, or herbal teas. Herbal remedies are seen by some as a treatment to be preferred to pure medical compounds that have been industrially produced.^[28]

In India the herbal remedy is so popular that the government of India has created a separate department—AYUSH—under the Ministry of Health & Family Welfare. The National Medicinal Plants Board was also established in 2000 by the Indian government in order to deal with the herbal medical system.^[29]

Herbal preparations[edit]

There are many forms in which herbs can be administered, the most common of which is in the form of a liquid that is drunk by the patient—either an herbal tea or a (possibly diluted) plant extract.^[30]

Several methods of standardization may be determining the amount of herbs used. One is the ratio of raw materials to solvent. However different specimens of even the same plant species may vary in chemical content. For this reason, thin layer chromatography is sometimes used by growers to assess the content of their products before use. Another method is standardization on a signal chemical.^[31]

Herbal teas, or tisanes, are the resultant liquid of extracting herbs into water, though they are made in a few different ways. Infusions are hot water extracts of herbs, such as chamomile or mint, through steeping. Decoctions are the long-term boiled extracts, usually of harder substances like roots or bark. Maceration is the cold infusion of plants with high mucilage-content, such as sage or thyme. To make macerates, plants are chopped and added to cold water. They are then left to stand for 7 to 12 hours (depending on herb used). For most macerates, 10 hours is used.^[32]

Tinctures are alcoholic extracts of herbs, which are generally stronger than herbal teas.^[33] Tinctures are usually obtained by combining 100% pure ethanol (or a mixture of 100% ethanol with water) with the herb. A completed tincture has an ethanol percentage of at least 25% (sometimes up to 90%).^[32] Herbal wine and elixirs are alcoholic extract of herbs, usually with an ethanol percentage of 12–38%.^[32]Extracts include liquid extracts, dry extracts, and nebulisates. Liquid extracts are liquids with a lower ethanol percentage than tinctures. They are usually made by vacuum distilling tinctures. Dry extracts are extracts of plant material that are evaporated into a dry mass. They can then be further refined to a capsule or tablet.^[32]

The exact composition of an herbal product is influenced by the method of extraction. A tea will be rich in polar components because water is a polar solvent. Oil on the other hand is a non-polar solvent and it will absorb non-polar compounds. Alcohol lies somewhere in between.^[30]

Many herbs are applied topically to the skin in a variety of forms. Essential oil extracts can be applied to the skin, usually diluted in a carrier oil. Many essential oils can burn the skin or are simply too high dose used straight; diluting them in olive oil or another food grade oil such as almond oil can allow these to be used safely as a topical. Salves, oils, balms, creams and lotions are other forms of topical delivery mechanisms. Most topical applications are oil extractions of herbs. Taking a food grade oil and soaking herbs in it for anywhere from weeks to months allows certain phytochemicals to be extracted into the oil. This oil can then be made into salves, creams, lotions, or simply used as an oil for topical application. Many massage oils, antibacterial salves, and wound healing compounds are made this way.^[34]

Inhalation, as in aromatherapy, can be used as a treatment.^[35][36][37]

Safety[edit]

A number of herbs are thought to be likely to cause adverse effects.^[39] Furthermore, 'adulteration, inappropriate formulation, or lack of understanding of plant and drug interactions have led to adverse reactions that are sometimes life threatening or lethal.'^[40] Proper double-blind clinical trials are needed to determine the safety and efficacy of each plant before they can be recommended for medical use.^[41] Although many consumers believe that herbal medicines are safe because they are 'natural', herbal medicines and synthetic drugs may interact, causing toxicity to the patient. Herbal remedies can also be dangerously contaminated, and herbal medicines without established efficacy, may unknowingly be used to replace medicines that do have corroborated efficacy.^[42]

Standardization of purity and dosage is not mandated in the United States, but even products made to the same specification may differ as a result of biochemical variations within a species of plant.^[43] Plants have chemical defense mechanisms against predators that can have adverse or lethal effects on humans. Examples of highly toxic herbs include poison hemlock and nightshade.^[44] They are not marketed to the public as herbs, because the risks are well known, partly due to a long and colorful history in Europe, associated with 'sorcery', 'magic' and intrigue.^[45] Although not frequent, adverse reactions have been reported for herbs in widespread use.^[46] On occasion serious untoward outcomes have been linked to herb consumption. A case of major potassium depletion has been attributed to chronic licorice ingestion.,^[47] and consequently professional herbalists avoid the use of licorice where they recognize that this may be a risk. Black cohosh has been implicated in a case of liver failure.^[48]Few studies are available on the safety of herbs for pregnant women,^[49] and one study found that use of complementary and alternative medicines are associated with a 30% lower ongoing pregnancy and live birth rate during fertility treatment.^[50] Examples of herbal treatments with likely cause-effect relationships with adverse events include aconite, which is often a legally restricted herb, ayurvedic remedies, broom, chaparral, Chinese herb mixtures, comfrey, herbs containing certain flavonoids, germander, guar gum, liquorice root, and pennyroyal.^[51] Examples of herbs where a high degree of confidence of a risk long term adverse effects can be asserted include ginseng, which is unpopular among herbalists for this reason, the endangered herb goldenseal, milk thistle, senna, against which herbalists generally advise and rarely use, aloe vera juice, buckthorn bark and berry, cascara sagrada bark, saw palmetto, valerian, kava, which is banned in the European Union, St. John's wort, Khat, Betel nut, the restricted herb Ephedra, and Guarana.^[40]

There is also concern with respect to the numerous well-established interactions of herbs and drugs.^[40][52] In consultation with a physician, usage of herbal remedies should be clarified, as some herbal remedies have the potential to cause adverse drug interactions when used in combination with various prescription and over-the-counter pharmaceuticals, just as a patient should inform a herbalist of their consumption of orthodox prescription and other medication.^[53][54]

For example, dangerously low blood pressure may result from the combination of an herbal remedy that lowers blood pressure together with prescription medicine that has the same effect. Some herbs may amplify the effects of anticoagulants.^[55]Certain herbs as well as common fruit interfere with cytochrome P450, an enzyme critical to much drug metabolism.^[56]

In a 2018 study, FDA identified active pharmaceutical additives in over 700 of analyzed dietary supplements sold as 'herbal', 'natural' or 'traditional'.^[57] The undisclosed additives included 'unapproved antidepressants and designer steroids', as well as prescription drugs, such as sildenafil or sibutramine.

Labeling accuracy[edit]

A 2013 study found that one-third of herbal supplements sampled contained no trace of the herb listed on the label.^[43] The study found products adulterated with contaminants or fillers not listed on the label, including potential allergens such as soy, wheat, or black walnut. One bottle labeled as St. John's Wort was found to actually contain Alexandrian senna, a laxative.^[43][58]

Researchers at the University of Adelaide found in 2014 that almost 20 per cent of herbal remedies surveyed were not registered with the Therapeutic Goods Administration, despite this being a condition for their sale.^[59] They also found that nearly 60 per cent of products surveyed had ingredients that did not match what was on the label. Out of 121 products, only 15 had ingredients that matched their TGA listing and packaging.^[59]

In 2015, the New York Attorney General issued cease and desist letters to four major U.S. retailers (GNC, Target, Walgreens, and Walmart) who were accused of selling herbal supplements that were mislabeled and potentially dangerous.^[60][61] Twenty-four products were tested by DNA barcoding as part of the investigation, with all but five containing DNA that did not match the product labels.

Practitioners of herbalism[edit]

Herbalists must learn many skills, including the wildcrafting or cultivation of herbs, diagnosis and treatment of conditions or dispensing herbal medication, and preparations of herbal medications. Education of herbalists varies considerably in different areas of the world. Lay herbalists and traditional indigenous medicine people generally rely upon apprenticeship and recognition from their communities in lieu of formal schooling.^{[citation needed]}

In some countries, formalized training and minimum education standards exist, although these are not necessarily uniform within or between countries. In Australia, for example, the self-regulated status of the profession (as of 2009) resulted in variable standards of training, and numerous loosely-formed associations setting different educational standards.^[62] One 2009 review concluded that regulation of herbalists in Australia was needed to reduce the risk of interaction of herbal medicines with prescription drugs, to implement clinical guidelines and prescription of herbal products, and to assure self-regulation for protection of public health and safety.^[62] In the United Kingdom, the training of herbalists is done by state funded universities offering Bachelor of Science degrees in herbal medicine.^[63]

Government regulations[edit]

The World Health Organization (WHO), the specialized agency of the United Nations (UN) that is concerned with international public health, published Quality control methods for medicinal plant materials in 1998 in order to support WHO Member States in establishing quality standards and specifications for herbal materials, within the overall context of quality assurance and control of herbal medicines.^[64]

In the European Union (EU), herbal medicines are regulated under the Committee on Herbal Medicinal Products.^[65]

In the United States, herbal remedies are regulated dietary supplements by the Food and Drug Administration (FDA) under current good manufacturing practice (cGMP) policy for dietary supplements.^[66] Manufacturers of products falling into this category are not required to prove the safety or efficacy of their product so long as they do not make 'medical' claims or imply uses other than as a 'dietary supplement', though the FDA may withdraw a product from sale should it prove harmful.^[67][68]

Canadian regulations are described by the Natural and Non-prescription Health Products Directorate which requires an eight-digit Natural Product Number or Homeopathic Medicine Number on the label of licensed herbal medicines or dietary supplements.^[69]

Some herbs, such as cannabis and coca, are outright banned in most countries though coca is legal in most of the South American countries where it is grown. The Cannabis plant is used as an herbal medicine, and as such is legal in some parts of the world. Since 2004, the sales of ephedra as a dietary supplement is prohibited in the United States by the FDA,^[70] and subject to Schedule III restrictions in the United Kingdom.

Scientific criticism[edit]

Herbalism has been criticized as a potential 'minefield' of unreliable product quality, safety hazards, and potential for misleading health advice.^[1][5] Globally, there are no standards across various herbal products to authenticate their contents, safety or efficacy,^[43] and there is generally an absence of high-quality scientific research on product composition or effectiveness for anti-disease activity.^[5][71] Presumed claims of therapeutic benefit from herbal products, without rigorous evidence of efficacy and safety, receive skeptical views by scientists.^[1]

Unethical practices by some herbalists and manufacturers, which may include false advertising about health benefits on product labels or literature,^[5] and contamination or use of fillers during product preparation,^[43][72] may erode consumer confidence about services and products.^[73][74]

Paraherbalism[edit]

Paraherbalism is the pseudoscientific use of extracts of plant or animal origin as supposed medicines or health-promoting agents.^[1][5][4] Phytotherapy differs from plant-derived medicines in standard pharmacology because it does not isolate and standardize the compounds from a given plant believed to be biologically active. It relies on the false belief that preserving the complexity of substances from a given plant with less processing is safer and potentially more effective, for which there is no evidence either condition applies.^[4]

Phytochemical researcher Varro Eugene Tyler described paraherbalism as 'faulty or inferior herbalism based on pseudoscience', using scientific terminology but lacking scientific evidence for safety and efficacy. Tyler listed ten fallacies that distinguished herbalism from paraherbalism, including claims that there is a conspiracy to suppress safe and effective herbs, herbs can not cause harm, that whole herbs are more effective than molecules isolated from the plants, herbs are superior to drugs, the doctrine of signatures (the belief that the shape of the plant indicates its function) is valid, dilution of substances increases their potency (a doctrine of the pseudoscience of homeopathy), astrological alignments are significant, animal testing is not appropriate to indicate human effects, anecdotal evidence is an effective means of proving a substance works and herbs were created by God to cure disease. Tyler suggests that none of these beliefs have any basis in fact.^[75][76]

Traditional systems[edit]

Africa[edit]

Up to 80% of the population in Africa uses traditional medicine as primary health care.^[77]

Americas[edit]

Native Americans medicinally used about 2,500 of the approximately 20,000 plant species that are native to North America.^[78]

China[edit]

Some researchers trained in both Western and traditional Chinese medicine have attempted to deconstruct ancient medical texts in the light of modern science. One idea is that the yin-yang balance, at least with regard to herbs, corresponds to the pro-oxidant and anti-oxidant balance. This interpretation is supported by several investigations of the ORAC ratings of various yin and yang herbs.^[79][80]

India[edit]

In India, Ayurvedic medicine has quite complex formulas with 30 or more ingredients, including a sizable number of ingredients that have undergone 'alchemical processing', chosen to balance dosha.^[81]

In Ladakh, Lahul-Spiti and Tibet, the Tibetan Medical System is prevalent, also called the 'Amichi Medical System'. Over 337 species of medicinal plants have been documented by C.P. Kala. Those are used by Amchis, the practitioners of this medical system.^[82][83]

In Tamil Nadu, Tamils have their own medicinal system now popularly called Siddha medicine. The Siddha system is entirely in the Tamil language. It contains roughly 300,000 verses covering diverse aspects of medicine. This work includes herbal, mineral and metallic compositions used as medicine. Ayurveda is in Sanskrit, but Sanskrit was not generally used as a mother tongue and hence its medicines are mostly taken from Siddha and other local traditions.^[84]

Indonesia[edit]

In Indonesia, especially among the Javanese, the jamu traditional herbal medicine is an age old tradition preserved for centuries. Jamu is thought to have originated in the Mataram Kingdom era, some 1300 years ago.^[85] The bas-reliefs on Borobudur depict the image of people grinding herbs with stone mortar and pestle, a drink seller, a physician and masseuse treating their clients.^[86] All of these scenes might be interpreted as a traditional herbal medicine and health-related treatments in ancient Java. The Madhawapura inscription from Majapahit period mentioned a specific profession of herbs mixer and combiner (herbalist), called Acaraki.^[86] The medicine book from Mataram dated from circa 1700 contains 3,000 entries of jamu herbal recipes, while Javanese classical literature Serat Centhini (1814) describes some jamu herbal concoction recipes.^[86]

Though possibly influenced by Indian Ayurveda systems, Indonesia's vast archipelago holds numerous indigenous plants not to be found in India, including plants similar to those in Australia beyond the Wallace Line. Jamu practices may vary from region to region, and are often not written down, especially in remote areas of the country.^[87] Although primarily herbal, some Jamu materials are acquired from animals, such as honey, royal jelly, milk and ayam kampungeggs.

Philosophy[edit]

Herbalists tend to use extracts from parts of plants, such as the roots or leaves,^[88] believing that plants are subject to environmental pressures and therefore develop resistance to threats such as radiation, reactive oxygen species and microbial attack in order to survive, providing defensive phytochemicals of use in herbalism.^[88][89]

Uses of herbal medicines by animals[edit]

Indigenous healers often claim to have learned by observing that sick animals change their food preferences to nibble at bitter herbs they would normally reject.^[90] Field biologists have provided corroborating evidence based on observation of diverse species, such as chickens, sheep, butterflies, and chimpanzee. The habit of changing diet has been shown to be a physical means of purging intestinal parasites. Lowland gorillas take 90%^{[verification needed]} of their diet from the fruits of Aframomum melegueta, a relative of the ginger plant, that is a potent antimicrobial and apparently keeps shigellosis and similar infections at bay.^[91] Current research focuses on the possibility that this plant also protects gorillas from fibrosing cardiomyopathy, which has a devastating effect on captive animals.^[92]

Sick animals tend to forage plants rich in secondary metabolites, such as tannins and alkaloids.^[93] Because these phytochemicals often have antiviral, antibacterial, antifungal, and antihelminthic properties, a plausible case can be made for self-medication by animals in the wild.^[91]

See also[edit]

References[edit]

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45. ^Lee, MR (December 2006). 'Solanaceae III: henbane, hags and Hawley Harvey Crippen'. J R Coll Physicians Edinb. 36 (4): 366–73. PMID17526134.
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48. ^Lynch, Christopher R.; Folkers, ME; Hutson, WR (June 2006). 'Fulminant hepatic failure associated with the use of black cohosh: a case report'. Liver Transpl. 12 (6): 989–92. doi:10.1002/lt.20778. PMID16721764.
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51. ^Ernst E (1998). 'Harmless Herbs? A Review of the Recent Literature'(PDF). The American Journal of Medicine. 104 (2): 170–78. doi:10.1016/S0002-9343(97)00397-5. PMID9528737. Retrieved 27 December 2010.
52. ^Izzo, Angelo A. (11 January 2012). 'Interactions between Herbs and Conventional Drugs: Overview of the Clinical Data'. Medical Principles and Practice. 21 (5): 404–428. doi:10.1159/000334488. ISSN1011-7571. PMID22236736. Retrieved 26 June 2019.
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55. ^Spolarich, AE; Andrews, L (Summer 2007). 'An examination of the bleeding complications associated with herbal supplements, antiplatelet and anticoagulant medications'. J Dent Hyg. 81 (3): 67. PMID17908423.
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57. ^Ronnie Cohen (12 October 2018). 'No Wonder It Works So Well: There May Be Viagra In That Herbal Supplement'. NPR.org. Retrieved 13 October 2018.
58. ^O'Connor, Anahad (3 November 2012). 'Herbal Supplements Are Often Not What They Seem'. New York Times. Retrieved 12 November 2013.
59. ^ ^abCarroll, Lucy (24 February 2014). 'Herbal medicines: Study raises alarm over labelling'. The Sydney Morning Herald, Australia. Retrieved 25 February 2017.
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70. ^FDA Issues Regulation Prohibiting Sale of Dietary Supplements Containing Ephedrine Alkaloids and Reiterates Its Advice That Consumers Stop Using These ProductsArchived 2007-09-15 at the Wayback Machine
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75. ^Tyler, VE; Robbers JE (1999). Tyler's Herbs of Choice: The Therapeutic Use of Phytomedicinals. Routledge. pp. 6–8. ISBN978-0789001597.
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87. ^Susan-Jane Beers, Jamu: The Ancient Indonesian Art of Herbal Healing (Hong Kong: Periplus, 2001)
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91. ^ ^abEngel, Cindy (2002). Wild Health: How Animals Keep Themselves Well and What We Can Learn From Them. Houghton Mifflin. ISBN978-0-618-07178-4.
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Further reading[edit]

• Aronson, Jeffrey K. (2008). Meyler's Side Effects of Herbal Medicines. Elsevier. ISBN9780080932903.
• Braun, Lesley & Cohen, Marc (2007). Herbs and Natural Supplements: An Evidence-Based Guide. Elsevier. ISBN9780729537964.

A hernia is the abnormal exit of tissue or an organ, such as the bowel, through the wall of the cavity in which it normally resides.^[1] Hernias come in a number of types.^[6] Most commonly they involve the abdomen, specifically the groin.^[6]Groin hernias are most common of the inguinal type but may also be femoral.^[1] Other hernias include hiatus, incisional, and umbilical hernias.^[6] Symptoms are present in about 66% of people with groin hernias.^[1] This may include pain or discomfort especially with coughing, exercise, or going to the bathroom.^[1] Often it gets worse throughout the day and improves when lying down.^[1] A bulging area may occur that becomes larger when bearing down.^[1] Groin hernias occur more often on the right than left side.^[1] The main concern is strangulation, where the blood supply to part of the bowel is blocked.^[1] This usually produces severe pain and tenderness of the area.^[1] Hiatus or hiatal hernias often result in heartburn but may also cause chest pain or pain with eating.^[3]

Risk factors for the development of a hernia include: smoking, chronic obstructive pulmonary disease, obesity, pregnancy, peritoneal dialysis, collagen vascular disease, and previous open appendectomy, among others.^[1][2][3] Hernias are partly genetic and occur more often in certain families.^[1] It is unclear if groin hernias are associated with heavy lifting.^[1] Hernias can often be diagnosed based on signs and symptoms.^[1] Occasionally medical imaging is used to confirm the diagnosis or rule out other possible causes.^[1] The diagnosis of hiatus hernias is often by endoscopy.^[3]

Groin hernias that do not cause symptoms in males do not need to be repaired.^[1] Repair, however, is generally recommended in women due to the higher rate of femoral hernias which have more complications.^[1] If strangulation occurs immediate surgery is required.^[1] Repair may be done by open surgery or by laparoscopic surgery.^[1] Open surgery has the benefit of possibly being done under local anesthesia rather than general anesthesia.^[1] Laparoscopic surgery generally has less pain following the procedure.^[1] A hiatus hernia may be treated with lifestyle changes such as raising the head of the bed, weight loss, and adjusting eating habits.^[3] The medications, H2 blockers or proton pump inhibitors may help.^[3] If the symptoms do not improve with medications the surgery known as laparoscopic fundoplication may be an option.^[3]

About 27% of males and 3% of females develop a groin hernia at some time in their life.^[1] Inguinal, femoral and abdominal hernias were present in 18.5 million people and resulted in 59,800 deaths in 2015.^[4][5] Groin hernias occur most often before the age of one and after the age of fifty.^[2] It is not known how commonly hiatus hernias occur with estimates in North America varying from 10 to 80%.^[3] The first known description of a hernia dates back to at least 1550 BC in the Ebers Papyrus from Egypt.^[7]

• 1Signs and symptoms
• 3Diagnosis
• 4Treatment

Signs and symptoms[edit]

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By far the most common hernias develop in the abdomen, when a weakness in the abdominal wall evolves into a localized hole, or 'defect', through which adipose tissue, or abdominal organs covered with peritoneum, may protrude. Another common hernia involves the spinal discs and causes sciatica. A hiatus hernia occurs when the stomach protrudes into the mediastinum through the esophageal opening in the diaphragm.

Hernias may or may not present with either pain at the site, a visible or palpable lump, or in some cases more vague symptoms resulting from pressure on an organ which has become 'stuck' in the hernia, sometimes leading to organ dysfunction. Fatty tissue usually enters a hernia first, but it may be followed or accompanied by an organ.

Hernias are caused by a disruption or opening in the fascia, or fibrous tissue, which forms the abdominal wall. It is possible for the bulge associated with a hernia to come and go, but the defect in the tissue will persist.

Symptoms and signs vary depending on the type of hernia. Symptoms may or may not be present in some inguinal hernias. In the case of reducible hernias, a bulge in the groin or in another abdominal area can often be seen and felt. When standing, such a bulge becomes more obvious. Besides the bulge, other symptoms include pain in the groin that may also include a heavy or dragging sensation, and in men, there is sometimes pain and swelling in the scrotum around the testicular area.^[8]

Irreducible abdominal hernias or incarcerated hernias may be painful, but their most relevant symptom is that they cannot return to the abdominal cavity when pushed in. They may be chronic, although painless, and can lead to strangulation (loss of blood supply), obstruction (kinking of intestine), or both. Strangulated hernias are always painful and pain is followed by tenderness. Nausea, vomiting, or fever may occur in these cases due to bowel obstruction. Also, the hernia bulge in this case may turn red, purple or dark and pink.

In the diagnosis of abdominal hernias, imaging is the principal means of detecting internal diaphragmatic and other nonpalpable or unsuspected hernias. Multidetector CT (MDCT) can show with precision the anatomic site of the hernia sac, the contents of the sac, and any complications. MDCT also offers clear detail of the abdominal wall allowing wall hernias to be identified accurately.^[9]

Complications[edit]

Complications may arise post-operation, including rejection of the mesh that is used to repair the hernia. In the event of a mesh rejection, the mesh will very likely need to be removed. Mesh rejection can be detected by obvious, sometimes localized swelling and pain around the mesh area. Continuous discharge from the scar is likely for a while after the mesh has been removed.

A surgically treated hernia can lead to complications such as inguinodynia, while an untreated hernia may be complicated by:

• Obstruction of any lumen, such as bowel obstruction in intestinal hernias
• Hydrocele of the hernial sac
• Autoimmune problems
• Irreducibility or Incarceration, in which it cannot be reduced, or pushed back into place,^[10] at least not without very much external effort.^[11] In intestinal hernias, this also substantially increases the risk of bowel obstruction and strangulation.

Causes[edit]

Causes of hiatus hernia vary depending on each individual. Among the multiple causes, however, are the mechanical causes which include: improper heavy weight lifting, hard coughing bouts, sharp blows to the abdomen, and incorrect posture.^[12]

Furthermore, conditions that increase the pressure of the abdominal cavity may also cause hernias or worsen the existing ones. Some examples would be: obesity, straining during a bowel movement or urination (constipation, enlarged prostate), chronic lung disease, and also, fluid in the abdominal cavity (ascites).^[13]

Also, if muscles are weakened due to poor nutrition, smoking, and overexertion, hernias are more likely to occur.

The physiological school of thought contends that in the case of inguinal hernia, the above-mentioned are only an anatomical symptom of the underlying physiological cause. They contend that the risk of hernia is due to a physiological difference between patients who suffer hernia and those who do not, namely the presence of aponeurotic extensions from the transversus abdominis aponeurotic arch.^[14]

Abdominal wall hernia may occur due to trauma. If this type of hernia is due to blunt trauma it is an emergency condition and could be associated with various solid organs and hollow viscus injuries.

Diagnosis[edit]

Inguinal[edit]

By far the most common hernias (up to 75% of all abdominal hernias) are the so-called inguinal hernias. Inguinal hernias are further divided into the more common indirect inguinal hernia (2/3, depicted here), in which the inguinal canal is entered via a congenital weakness at its entrance (the internal inguinal ring), and the direct inguinal hernia type (1/3), where the hernia contents push through a weak spot in the back wall of the inguinal canal. Inguinal hernias are the most common type of hernia in both men and women. In some selected cases, they may require surgery. There are special cases in which the hernia may contain both direct and indirect hernia simultaneously pantaloon hernia, or, though very rare, may contain simultaneous indirect hernias.^[15]

Pantaloon hernia (Saddle Bag hernia) is a combined direct and indirect hernia, when the hernial sac protrudes on either side of the inferior epigastric vessels.

Femoral[edit]

Femoral hernias occur just below the inguinal ligament, when abdominal contents pass into the weak area at the posterior wall of the femoral canal. They can be hard to distinguish from the inguinal type (especially when ascending cephalad): however, they generally appear more rounded, and, in contrast to inguinal hernias, there is a strong female preponderance in femoral hernias. The incidence of strangulation in femoral hernias is high. Repair techniques are similar for femoral and inguinal hernia.

A Cooper's hernia is a femoral hernia with two sacs, the first being in the femoral canal, and the second passing through a defect in the superficial fascia and appearing almost immediately beneath the skin.

Umbilical[edit]

They involve protrusion of intra-abdominal contents through a weakness at the site of passage of the umbilical cord through the abdominal wall. Umbilical hernias in adults are largely acquired, and are more frequent in obese or pregnant women. Abnormal decussation of fibers at the linea alba may contribute.

Incisional[edit]

An incisional hernia occurs when the defect is the result of an incompletely healed surgical wound. When these occur in median laparotomy incisions in the linea alba, they are termed ventral hernias. These can be the most frustrating and difficult to treat, as the repair utilizes already attenuated tissue.

Diaphragmatic[edit]

Higher in the abdomen, an (internal) 'diaphragmatic hernia' results when part of the stomach or intestine protrudes into the chest cavity through a defect in the diaphragm.

A hiatus hernia is a particular variant of this type, in which the normal passageway through which the esophagus meets the stomach (esophageal hiatus) serves as a functional 'defect', allowing part of the stomach to (periodically) 'herniate' into the chest. Hiatus hernias may be either 'sliding', in which the gastroesophageal junction itself slides through the defect into the chest, or non-sliding (also known as para-esophageal), in which case the junction remains fixed while another portion of the stomach moves up through the defect. Non-sliding or para-esophageal hernias can be dangerous as they may allow the stomach to rotate and obstruct. Repair is usually advised.

A congenital diaphragmatic hernia is a distinct problem, occurring in up to 1 in 2000 births, and requiring pediatric surgery. Intestinal organs may herniate through several parts of the diaphragm, posterolateral (in Bochdalek's triangle, resulting in Bochdalek's hernia), or anteromedial-retrosternal (in the cleft of Larrey/Morgagni's foramen, resulting in Morgagni-Larrey hernia, or Morgagni's hernia).^[16]

Other hernias[edit]

Since many organs or parts of organs can herniate through many orifices, it is very difficult to give an exhaustive list of hernias, with all synonyms and eponyms. The above article deals mostly with 'visceral hernias', where the herniating tissue arises within the abdominal cavity. Other hernia types and unusual types of visceral hernias are listed below, in alphabetical order:

• Abdominal wall hernias:
  • Epigastric hernia: a hernia through the linea alba above the umbilicus.
  • Spigelian hernia, also known as spontaneous lateral ventral hernia
• Amyand's hernia: containing the appendix vermiformis within the hernia sac
• Brain herniation, sometimes referred to as brain hernia, is a potentially deadly side effect of very high intracranial pressure that occurs when a part of the brain is squeezed across structures within the skull.
• Double indirect hernia: an indirect inguinal hernia with two hernia sacs, without a concomitant direct hernia component (as seen in a pantaloon hernia).^[15]
• Hiatus hernia: a hernia due to 'short oesophagus' — insufficient elongation — stomach is displaced into the thorax
• Littre's hernia: a hernia involving a Meckel's diverticulum. It is named after the French anatomist Alexis Littré (1658–1726).
• Lumbar hernia: a hernia in the lumbar region (not to be confused with a lumbar disc hernia), contains the following entities:
  • Petit's hernia: a hernia through Petit's triangle (inferior lumbar triangle). It is named after French surgeon Jean Louis Petit (1674–1750).
  • Grynfeltt's hernia: a hernia through Grynfeltt-Lesshaft triangle (superior lumbar triangle). It is named after physician Joseph Grynfeltt (1840–1913).
• Maydl's hernia: two adjacent loops of small intestine are within a hernial sac with a tight neck. The intervening portion of bowel within the abdomen is deprived of its blood supply and eventually becomes necrotic.
• Obturator hernia: hernia through obturator canal

• Parastomal hernias, which is when tissue protrudes adjacent to a stoma tract.
• Paraumbilical hernia: a type of umbilical hernia occurring in adults
• Perineal hernia: a perineal hernia protrudes through the muscles and fascia of the perineal floor. It may be primary but usually is acquired following perineal prostatectomy, abdominoperineal resection of the rectum, or pelvic exenteration.
• Properitoneal hernia: rare hernia located directly above the peritoneum, for example, when part of an inguinal hernia projects from the deep inguinal ring to the preperitoneal space.
• Richter's hernia: a hernia involving only one sidewall of the bowel, which can result in bowel strangulation leading to perforation through ischaemia without causing bowel obstruction or any of its warning signs. It is named after German surgeon August Gottlieb Richter (1742–1812).
• Sliding hernia: occurs when an organ drags along part of the peritoneum, or, in other words, the organ is part of the hernia sac. The colon and the urinary bladder are often involved. The term also frequently refers to sliding hernias of the stomach.
• Sciatic hernia: this hernia in the greater sciatic foramen most commonly presents as an uncomfortable mass in the gluteal area. Bowel obstruction may also occur. This type of hernia is only a rare cause of sciatic neuralgia.
• Sports hernia: a hernia characterized by chronic groin pain in athletes and a dilated superficial inguinal ring.
• Velpeau hernia: a hernia in the groin in front of the femoral blood vessels

Treatment[edit]

Truss[edit]

The benefits of the use of an external device to maintain reduction of the hernia without repairing the underlying defect (such as hernia trusses, trunks, belts, etc.) are unclear.^[1]

Surgery[edit]

Surgery is recommended for some types of hernias to prevent complications like obstruction of the bowel or strangulation of the tissue, although umbilical hernias and hiatus hernias may be watched, or are treated with medication.^[17] Most abdominal hernias can be surgically repaired, but surgery has complications. Time needed for recovery after treatment is reduced if hernias are operated on laparoscopically. However, open surgery can be done sometimes without general anesthesia. Uncomplicated hernias are principally repaired by pushing back, or 'reducing', the herniated tissue, and then mending the weakness in muscle tissue (an operation called herniorrhaphy). If complications have occurred, the surgeon will check the viability of the herniated organ and remove part of it if necessary.

Muscle reinforcement techniques often involve synthetic materials (a mesh prosthesis).^[18] The mesh is placed either over the defect (anterior repair) or under the defect (posterior repair). At times staples are used to keep the mesh in place. These mesh repair methods are often called 'tension free' repairs because, unlike some suture methods (e.g., Shouldice), muscle is not pulled together under tension. However, this widely used terminology is misleading, as there are many tension-free suture methods that do not use mesh (e.g., Desarda, Guarnieri, Lipton-Estrin, etc.).

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Evidence suggests that tension-free methods (with or without mesh) often have lower percentage of recurrences and the fastest recovery period compared to tension suture methods. However, among other possible complications, prosthetic mesh usage seems to have a higher incidence of chronic pain and, sometimes, infection.^[19]

The frequency of surgical correction ranges from 10 per 100,000 (U.K.) to 28 per 100,000 (U.S.).^[1]

Recovery[edit]

Many people are managed through day surgery centers, and are able to return to work within a week or two, while intense activities are prohibited for a longer period. People who have their hernias repaired with mesh often recover within a month, though pain can last longer. Surgical complications include pain that lasts more than three months, surgical site infections, nerve and blood vessel injuries, injury to nearby organs, and hernia recurrence. Pain that lasts more than three months occurs in about 10% of people following hernia repair.^[1]

Epidemiology[edit]

About 27% of males and 3% of females develop a groin hernia at some time in their lives.^[1] In 2013 about 25 million people had a hernia.^[20] Inguinal, femoral and abdominal hernias resulted in 32,500 deaths globally in 2013 and 50,500 in 1990.^[21]

References[edit]

1. ^ ^{abcdefghijklmnopqrstuvwxyzaaabacad}Fitzgibbons RJ, Jr; Forse, RA (19 February 2015). 'Clinical practice. Groin hernias in adults'. The New England Journal of Medicine. 372 (8): 756–63. doi:10.1056/NEJMcp1404068. PMID25693015.
2. ^ ^abcdDomino, Frank J. (2014). The 5-minute clinical consult 2014 (22nd ed.). Philadelphia, Pa.: Wolters Kluwer Health/Lippincott Williams & Wilkins. p. 562. ISBN9781451188509. Archived from the original on 2017-08-22.
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External links[edit]

• Hernia at Curlie