Hernias almost always worsen and surgery is required

Q: If you've got an abdominal hernia and it doesn't bother you, can you just leave it alone? How is it treated? I've read about using mesh, but apparently some of them have turned out to be defective.

A: The muscles that surround the abdominal cavity play a number of important roles. They support upright posture and controlled movement, aid in breathing and play a role in urination, bowel movements, coughing, singing, vomiting and childbirth. They also keep the abdominal organs, tissues and intestines safely in place.

When these muscles develop an opening that allows fatty tissue or a portion of the intestine to protrude, it's known as a hernia. Although the majority of hernias develop in the abdominal area, they can also occur in the region of the groin and the upper thigh.

Abdominal hernias are common. They can occur in anyone, including babies, children and women, but are most often seen in men over the age of 40. When a hernia develops, you will notice a swelling or lump that is present when you're standing up or using your abdominal muscles. The swelling will often vanish when you lie down. The condition is usually pain-free in its early stages. Some people report feeling pressure, or a tugging sensation, at the site of the hernia. None of the different types of hernia will heal on its own.

When a hernia is small and painless, some doctors recommend watchful waiting, perhaps with the use of supportive garments. But studies have shown that when left untreated, a hernia will often continue to grow in size and eventually begin to cause pain. In the most severe cases, a hernia can become strangulated. This occurs when the surrounding muscle contracts and cuts off the blood supply to the protruding tissue. That means a portion of intestines inside the body are also starved of blood.

Symptoms of a strangulated hernia include sudden and severe pain, bloody stool, fever, nausea and vomiting, inability to pass gas, constipation and exhaustion. A strangulated hernia is a serious and life-threatening condition that requires immediate medical treatment.

Hernias that grow larger over time or begin to cause pain require surgical repair. The procedure involves first returning the displaced tissues to their proper place in the abdomen, and then repairing the gap in the muscles. This is done by either sewing a patch of surgical mesh over the weakened area or with stitches.

The procedure can be a laparoscopic surgery, which is a minimally invasive technique performed through tiny incisions in the abdomen, or via open surgery. This involves the same series of repairs, but through a larger incision. In most cases, a hernia repair is an outpatient procedure and doesn't require an overnight hospital stay.

Hernias have a high rate of recurrence, and surgical mesh is most effective at strengthening the weakened area. And, while it's true some brands of surgical mesh have been subject to recalls, those products are no longer on the market. Be sure to share your concerns with your surgeon, who will help you choose the best treatment for your specific situation.

Q: I was recently diagnosed with chondrocalcinosis, which is quite painful. I know it's similar to gout, though it is due to calcium crystals rather than urea. What treatments can help with pain? I don't want to have a second knee replacement.

A: You're correct that the term chondrocalcinosis refers to a buildup of calcium crystals, specifically calcium pyrophosphate dihydrate crystals, within a joint. Sometimes referred to as pseudogout, it's most often seen in the knee, but can also affect the elbow, shoulder, wrist and ankle joints.

The accumulated crystals in the joint trigger an immune response, which results in inflammation, stiffness, swelling and pain within the joint. Episodes can last anywhere from several days to several months. The condition is often detected via an X-ray, which makes it possible to see the accumulation of calcium deposits.

It's a tricky diagnosis, though, because stiff and aching joints, and additional symptoms such as warmth and redness, are also common to osteoarthritis and rheumatoid arthritis. For a definitive diagnosis, a bit of fluid is removed from an inflamed joint and tested for the presence of calcium pyrophosphate crystals.

Anyone can develop chondrocalcinosis, but the risk rises significantly with advancing age. According to some estimates, it's found in up to one-fifth of people over the age of 60, and in half of those 90 and older. As with gout, the condition can cause both short- and long-term swelling in the articulated, or movable, joints. Some people have flare-ups in more than one joint, and some also experiences a low-grade fever.

Although a specific cause for chondrocalcinosis hasn't yet been identified, it is seen more often in people who have high blood levels of calcium (hypercalcemia), of iron (hemochromatosis), or hypomagnesemia, which is too little magnesium. Diet does not appear to play a role in flare-ups.

We're sorry to say that at this time, there is no known way to dissolve or remove the calcium pyrophosphate crystals within the joint. Instead, the emphasis is on managing the condition. The goal is to ease inflammation and pain and to limit the degenerative tissue damage that the condition can cause.

During flare-ups, nonsteroidal anti-inflammatory drugs, or NSAIDs, can ease pain, stiffness and swelling. For people who take blood thinners, or those who have stomach ulcers or poor kidney function, the use of NSAIDs may not be an option. In those cases, an aspiration procedure to remove fluid from the joint, along with an injection of a corticosteroid to manage inflammation, can provide relief.

There is evidence that low doses of a medication used for gout, known as colchicine, can be effective in limiting flare-ups.

You mentioned the possibility of a knee replacement. This is a procedure that is sometimes recommended in more serious cases. If your particular case of chondrocalcinosis is severe enough that this has been presented as an option, we recommend you seek guidance from a rheumatologist. These are physicians who specialize in the diagnosis and treatment of musculoskeletal disease and have an expertise in this painful and sometimes debilitating condition. Your health care provider should be able to provide you with a referral.

• Dr. Eve Glazier is an internist and associate professor of medicine at UCLA Health. Dr. Elizabeth Ko is an internist and assistant professor of medicine at UCLA Health. Send your questions to askthedoctors@mednet.ucla.edu.