Internal hernia: Complex diagnostic and therapeutic problem

Paraduodenal hernias are the most common type of congenital internal hernia. Because of its overall rare incidence, this entity is often overlooked during initial assessment of the patient. Lack of specific diagnostic criteria also makes diagnosis exceedingly difficult, and the resulting diagnostic delays can lead to tragic outcomes for patients. Despite these perceived barriers to timely diagnosis, there may be specific radiographic findings that, when combined with the appropriate constellation of clinical symptoms, would aid in diagnosis. This patient first presented at 8 years of age with vague symptoms of postprandial emesis, chronic abdominal pain, nausea, and syncope. Over the span of 6 years he was evaluated 2 to 3 times a year with similar complaints, all of which quickly resolved spontaneously. He underwent multiple laboratory, imaging, and endoscopic studies, which were nondiagnostic. It was not until he developed signs of a high-grade obstruction and extremis that he was found to have a large left paraduodenal hernia that had volvulized around the superior mesenteric axis. This resulted in the loss of the entire superior mesenteric axis distribution of the small and large intestine and necrosis of the duodenum. In cases of chronic intermittent obstruction without clear etiology, careful attention and consideration should be given to the constellation of symptoms, imaging studies, and potential use of diagnostic laparoscopy. Increased vigilance by primary care and consulting physicians is necessary to detect this rare but readily correctable condition.Internal hernias (IHs) are a rare clinical entity that cause 0.6% to 5.8% of small bowel obstructions. 1 There are 2 broad categories of IH: acquired and congenital. These are further categorized by location, which include paraduodenal, transmesenteric, and supra-or perivesical IHs and those located at the Foramen of Winslow. 2,3 Paraduodenal hernias (PDHs) are thought to be the most common type of congenital IH. 2,3 However, with the increasing incidence of procedures that require Roux-en-Y reconstruction, such as gastric bypass surgery, Kasai, choledochal cyst excision, and pediatric liver transplantation, the incidence of acquired IH is increasing. 4 Left PDH refers to a herniation of the small bowel into a mesenteric defect to the left of the inferior mesenteric vein (IMV) with a hernia sac within the leaflets of the left colon mesentery. 5 Symptoms can range from intermittent partial bowel obstruction in cases of spontaneously reducing IH to acute high-grade obstruction that occurs with incarceration or volvulus. 6 Radiographic diagnosis is made difficult because of the often intermittent nature of the disease, in which spontaneous reduction in and resolution of symptoms can occur by the time diagnostic imaging is performed. 2,7 Even when present, Dr Shi drafted the initial manuscript; Ms Felsted assisted in drafting the initial manuscript; Dr Masand provided radiographic expertise, drafted the figure legends, and reviewed and revised the ma...

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“…1,6,[8][9][10] When strangulation is present, mortality can approach 50%. 8 This makes expedient diagnosis and intervention paramount.…”

Section: Figurementioning

confidence: 99%

Congenital Left Paraduodenal Hernia Causing Chronic Abdominal Pain and Abdominal Catastrophe

Shi¹,

Felsted²,

Masand³

et al. 2015

Pediatrics

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“…In older literature, congenital internal hernias were the most frequent types of all IHs, but recent studies report the increase of the acquired types [10,11]. The surgical treatment results for congenital types were also much better than the results for acquired types [12][13][14][15]. Delayed laparotomy time (>3 days after the onset of the symptoms) and the presence of a comorbidity were related to high morbidity [16].…”

Section: Discussionmentioning

confidence: 99%

Small intestinal perforations due to acquired internal herniation

Öter¹

2018

Ann Clin Anal Med

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Aim: An internal hernia is a very rare cause of acute small bowel obstruction and perforation which may be difficult to diagnose. We aimed to provide a retrospective study for management and evaluated patients who underwent surgery for perforation due to intestinal internal herniation in our department. Material and Method: From January 2012 to April 2017, seven patients underwent surgery for a perforation due to intestinal internal herniation at our clinic. We retrospectively reviewed the patients' records, imaging modalities, and operative findings. Results: There were two women and five men with a mean age of 52.50

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“…The obturator hernia is rare and is observed in older women, with a major frequency in the Chinese races [1][2][3]. Commonly, patients present with symptoms of intestinal obstruction [4][5][6][7].…”

Section: Introductionmentioning

confidence: 99%

A successful case report in woman: A gender medicine?

Laviscio¹,

Ciarambino²,

Imbriani³

et al. 2019

Arch Surg Clin Res

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Introduction:Abdominal hernia is a pathological condition resulting from abnormal protrusion of abdominal viscera. In particular, internal hernias (IH) represents about 0.2-0.9% of all cases with para-duodenal hernias while obturator hernias accounting for only 0.07% of all hernias. Methods:We reported the case report of 79 year old women who was admitted to Internal Medicine Department of our Hospital for lung failure and after few days transferred to our Surgery Department for abdominal pain. Conclusion:Obturator hernia is rare type of hernia and it is more frequent in older women with history of multiple pregnancy, chronic cough, and habitual constipation. In our patients, detailed physical examination and MRI preoperative imaging studies, have induce to the successful diagnosis.

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Internal hernia: Complex diagnostic and therapeutic problem

Abstract: Acquired IH is becoming the most prevalent type of IH. They usually have rapid progression to bowel ischemia, so they have bad outcome. High index of suspicion is mandatory since the main factors that may influence the prognosis of affected patients are early diagnosis and therapy.

Cited by 60 publications

References 18 publications

Congenital Left Paraduodenal Hernia Causing Chronic Abdominal Pain and Abdominal Catastrophe

Congenital Left Paraduodenal Hernia Causing Chronic Abdominal Pain and Abdominal Catastrophe

Small intestinal perforations due to acquired internal herniation

A successful case report in woman: A gender medicine?

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