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Left paraduodenal hernia causing small bowel obstruction in an adolescent patient
Journal of Pediatric Surgery (2009) 44, 2417–2419
www.elsevier.com/locate/jpedsurg
Pediatric surgical image
Left paraduodenal hernia causing small bowel obstruction in an adolescent patient Brian P. Teng a , Sani Ziad Yamout a,b,⁎ a
Department of Surgery, SUNY-Buffalo, NY 14203, USA Division of Pediatric Surgery, Women and Children's Hospital of Buffalo, Buffalo, NY 14222, USA
b
Received 17 August 2009; revised 22 September 2009; accepted 23 September 2009
Key words: Internal hernia; Paraduodenal hernia; Fossa of Landzert
Abstract Internal hernias are an uncommon cause of bowel obstruction, accounting for less than 1% of cases. Paraduodenal hernias, the most common type of internal hernias, are believed to be congenital in origin. They can be asymptomatic, cause chronic abdominal pain, or present with acute intestinal obstruction with strangulation and ischemia. We describe a case of left paraduodenal hernia found in a patient who presented with acute intestinal obstruction. © 2009 Elsevier Inc. All rights reserved.
Internal hernias are an uncommon cause of bowel obstruction, accounting for less than 1% of cases [1]. Paraduodenal hernias, the most common type of internal hernias, are believed to be congenital in origin. They can be asymptomatic, cause chronic abdominal pain, or present with acute intestinal obstruction with strangulation and ischemia. We describe a case of left paraduodenal hernia found in a patient who presented with acute intestinal obstruction.
1. Case report A 16-year-old boy presented to an outside hospital after several hours of severe and constant diffuse abdominal pain. The pain woke him from sleep and was followed by nonbilious emesis consistent with gastric contents. He was previously asymptomatic without any contact with sick individuals. He
⁎ Corresponding author. Division of Pediatric Surgery, Women and Children's Hospital of Buffalo, Buffalo, NY 14222, USA. Tel.: +1 716 430 3242; fax: +1 716 888 3850. E-mail address: [email protected] (S.Z. Yamout). 0022-3468/$ – see front matter © 2009 Elsevier Inc. All rights reserved. doi:10.1016/j.jpedsurg.2009.09.020
also denied any history of weight loss, chronic abdominal pain, or other gastrointestinal symptoms. His evaluation at the outside hospital included a computed tomography (CT) scan of the abdomen and pelvis, which was interpreted as being consistent with intestinal volvulus. He was then transported to our facility by air ambulance. On initial examination, the patient appeared in moderate distress. His vital signs were normal except for a mildly elevated blood pressure. He had minimal pain but had received multiple medications including narcotics and benzodiazepines before the transfer. Laboratory studies were significant for an elevated white blood cell count of 16,400 with a left shift on differential smear. His CT scan was not available to the surgical team at the time of initial evaluation, and because of the lack of any signs of an intraabdominal catastrophe, an upper gastrointestinal (GI) contrast study was performed, to evaluate for malrotation. The upper GI study showed no flow of contrast out of the stomach (Fig. 1). At this point, the abdominal CT became available to us, and we confirmed the suspicion for intestinal volvulus (Fig. 2). The patient was taken to the operating room urgently for exploratory laparotomy, which showed dusky but viable
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small bowel, twisted upon its mesentery and entrapped in a large left paraduodenal space (Fig. 3). Once the bowel was reduced from the paraduodenal space and the volvulus untwisted, blood flow was reestablished and the small bowel resumed a healthy appearance. Upon inspection, the position of the ligament of Trietz was normal, and there were no other signs of malrotation. The paraduodenal space was closed by approximating the mesocolon to the base of the mesentery, taking care not to injure the inferior mesenteric vein. The patient's subsequent hospital course was uneventful, and he was discharged in satisfactory condition 4 days postoperatively.
2. Discussion Internal hernias are an uncommon cause of intestinal obstruction and occur when abdominal contents are trapped within a compartment of the abdominal cavity. Paraduodenal hernias are responsible for less than 1% of cases of intestinal obstruction but comprise 50% of internal hernias [1]. There are many controversies and theories regarding the exact origin of paraduodenal hernias, but the most widely accepted theory is that they result from an error in intestinal rotation and fixation that leads to entrapment of the small bowel between the mesocolon and posterior abdominal wall. Normally, the paraduodenal folds form a shallow space adjacent to the duodenum, the paraduodenal fossa. In the case of paraduodenal hernias, the paraduodenal fossa is deep and can encompass the entire small bowel. The hernia space is bound anteriorly by the mesocolon and posteriorly by the posterior abdominal wall. Paraduodenal hernias can occur to the right or left of the duodenum, with the left-sided type accounting for 75% of cases. Many different left paraduodenal fossae have been described based on small variations in location, the most common of which is the fossa of Landzert [1,2].
Fig. 1
Upper GI showing retention of contrast in the stomach.
Fig. 2 Computed tomographic scan showing poorly perfused, incarcerated loops of small bowel.
Diagnosis of paraduodenal hernias is difficult because of the absence of specific physical findings. These hernias may be completely asymptomatic, or present with chronic abdominal pain, bowel obstruction, and/or strangulation [3]. An abdominal CT is the most useful diagnostic study. Findings include clustering of small bowel loops, a wellcircumscribed edge corresponding to the hernia sac, mass effect on the posterior stomach wall, and stretched and engorged mesenteric vessels [4]. Operative repair involves reduction of the hernia contents and closure of the paraduodenal defect. Occasionally, the paraduodenal defect may need to be enlarged to reduce the engorged loops of bowel. Incising the mesocolon through an avascular section distal to the lower edge of the paraduodenal defect avoids injury to vessels in the mesocolon [5]. Once the incarcerated small bowel is reduced, the defect must be closed, taking care not to injure the adjacent mesenteric vessels, particularly the inferior mesenteric vein. Paraduodenal hernias are associated with intestinal ischemia in 20% of cases, which is partly attributable to the difficulty in achieving a diagnosis, with resultant delay in treatment. The reported 20% mortality rate also reflects the problems with delayed therapy. As to incidentally noted
Fig. 3
Diagram of intraoperative findings.
Left paraduodenal hernia in an adolescent patient paraduodenal defects, the 50% reported lifetime risk of incarceration mandates that it be repaired [6].
References [1] Berardi RS. Paraduodenal hernias. Surg Gynecol Obstet 1981;152: 99-110. [2] Nishida T, Mizushima T, Kitagawa T, et al. Unusual type of left paraduodenal hernia caused by a separated peritoneal membrane. J Gastroenterol 2002;37:742-4.
2419 [3] Blachar A, Federle MP, Brancatelli G, et al. Radiologist performance in the diagnosis of internal hernia by using specific CT findings with emphasis on transmesenteric hernia. Radiology 2001; 221:422-8. [4] Callander C, Rusk R, Nemir A. Mechanism, symptoms and treatment of hernia into the descending mesocolon (left duodenal hernia). Surg Gynecol Obstet 1935;60:1052-71. [5] Manji R, Warnock GL. Left paraduodenal hernia: an unusual cause of small-bowel obastruction. Canadian J Surg 2001;44:455-7. [6] Kurachi K, Nakamura T, Hayashi T, et al. Left paraduodenal hernia in an adult complicated by ascending colon cancer: a case report. World J Gastroenterol 2006;12:1795-7.
www.elsevier.com/locate/jpedsurg
Pediatric surgical image
Left paraduodenal hernia causing small bowel obstruction in an adolescent patient Brian P. Teng a , Sani Ziad Yamout a,b,⁎ a
Department of Surgery, SUNY-Buffalo, NY 14203, USA Division of Pediatric Surgery, Women and Children's Hospital of Buffalo, Buffalo, NY 14222, USA
b
Received 17 August 2009; revised 22 September 2009; accepted 23 September 2009
Key words: Internal hernia; Paraduodenal hernia; Fossa of Landzert
Abstract Internal hernias are an uncommon cause of bowel obstruction, accounting for less than 1% of cases. Paraduodenal hernias, the most common type of internal hernias, are believed to be congenital in origin. They can be asymptomatic, cause chronic abdominal pain, or present with acute intestinal obstruction with strangulation and ischemia. We describe a case of left paraduodenal hernia found in a patient who presented with acute intestinal obstruction. © 2009 Elsevier Inc. All rights reserved.
Internal hernias are an uncommon cause of bowel obstruction, accounting for less than 1% of cases [1]. Paraduodenal hernias, the most common type of internal hernias, are believed to be congenital in origin. They can be asymptomatic, cause chronic abdominal pain, or present with acute intestinal obstruction with strangulation and ischemia. We describe a case of left paraduodenal hernia found in a patient who presented with acute intestinal obstruction.
1. Case report A 16-year-old boy presented to an outside hospital after several hours of severe and constant diffuse abdominal pain. The pain woke him from sleep and was followed by nonbilious emesis consistent with gastric contents. He was previously asymptomatic without any contact with sick individuals. He
⁎ Corresponding author. Division of Pediatric Surgery, Women and Children's Hospital of Buffalo, Buffalo, NY 14222, USA. Tel.: +1 716 430 3242; fax: +1 716 888 3850. E-mail address: [email protected] (S.Z. Yamout). 0022-3468/$ – see front matter © 2009 Elsevier Inc. All rights reserved. doi:10.1016/j.jpedsurg.2009.09.020
also denied any history of weight loss, chronic abdominal pain, or other gastrointestinal symptoms. His evaluation at the outside hospital included a computed tomography (CT) scan of the abdomen and pelvis, which was interpreted as being consistent with intestinal volvulus. He was then transported to our facility by air ambulance. On initial examination, the patient appeared in moderate distress. His vital signs were normal except for a mildly elevated blood pressure. He had minimal pain but had received multiple medications including narcotics and benzodiazepines before the transfer. Laboratory studies were significant for an elevated white blood cell count of 16,400 with a left shift on differential smear. His CT scan was not available to the surgical team at the time of initial evaluation, and because of the lack of any signs of an intraabdominal catastrophe, an upper gastrointestinal (GI) contrast study was performed, to evaluate for malrotation. The upper GI study showed no flow of contrast out of the stomach (Fig. 1). At this point, the abdominal CT became available to us, and we confirmed the suspicion for intestinal volvulus (Fig. 2). The patient was taken to the operating room urgently for exploratory laparotomy, which showed dusky but viable
2418
B.P. Teng, S.Z. Yamout
small bowel, twisted upon its mesentery and entrapped in a large left paraduodenal space (Fig. 3). Once the bowel was reduced from the paraduodenal space and the volvulus untwisted, blood flow was reestablished and the small bowel resumed a healthy appearance. Upon inspection, the position of the ligament of Trietz was normal, and there were no other signs of malrotation. The paraduodenal space was closed by approximating the mesocolon to the base of the mesentery, taking care not to injure the inferior mesenteric vein. The patient's subsequent hospital course was uneventful, and he was discharged in satisfactory condition 4 days postoperatively.
2. Discussion Internal hernias are an uncommon cause of intestinal obstruction and occur when abdominal contents are trapped within a compartment of the abdominal cavity. Paraduodenal hernias are responsible for less than 1% of cases of intestinal obstruction but comprise 50% of internal hernias [1]. There are many controversies and theories regarding the exact origin of paraduodenal hernias, but the most widely accepted theory is that they result from an error in intestinal rotation and fixation that leads to entrapment of the small bowel between the mesocolon and posterior abdominal wall. Normally, the paraduodenal folds form a shallow space adjacent to the duodenum, the paraduodenal fossa. In the case of paraduodenal hernias, the paraduodenal fossa is deep and can encompass the entire small bowel. The hernia space is bound anteriorly by the mesocolon and posteriorly by the posterior abdominal wall. Paraduodenal hernias can occur to the right or left of the duodenum, with the left-sided type accounting for 75% of cases. Many different left paraduodenal fossae have been described based on small variations in location, the most common of which is the fossa of Landzert [1,2].
Fig. 1
Upper GI showing retention of contrast in the stomach.
Fig. 2 Computed tomographic scan showing poorly perfused, incarcerated loops of small bowel.
Diagnosis of paraduodenal hernias is difficult because of the absence of specific physical findings. These hernias may be completely asymptomatic, or present with chronic abdominal pain, bowel obstruction, and/or strangulation [3]. An abdominal CT is the most useful diagnostic study. Findings include clustering of small bowel loops, a wellcircumscribed edge corresponding to the hernia sac, mass effect on the posterior stomach wall, and stretched and engorged mesenteric vessels [4]. Operative repair involves reduction of the hernia contents and closure of the paraduodenal defect. Occasionally, the paraduodenal defect may need to be enlarged to reduce the engorged loops of bowel. Incising the mesocolon through an avascular section distal to the lower edge of the paraduodenal defect avoids injury to vessels in the mesocolon [5]. Once the incarcerated small bowel is reduced, the defect must be closed, taking care not to injure the adjacent mesenteric vessels, particularly the inferior mesenteric vein. Paraduodenal hernias are associated with intestinal ischemia in 20% of cases, which is partly attributable to the difficulty in achieving a diagnosis, with resultant delay in treatment. The reported 20% mortality rate also reflects the problems with delayed therapy. As to incidentally noted
Fig. 3
Diagram of intraoperative findings.
Left paraduodenal hernia in an adolescent patient paraduodenal defects, the 50% reported lifetime risk of incarceration mandates that it be repaired [6].
References [1] Berardi RS. Paraduodenal hernias. Surg Gynecol Obstet 1981;152: 99-110. [2] Nishida T, Mizushima T, Kitagawa T, et al. Unusual type of left paraduodenal hernia caused by a separated peritoneal membrane. J Gastroenterol 2002;37:742-4.
2419 [3] Blachar A, Federle MP, Brancatelli G, et al. Radiologist performance in the diagnosis of internal hernia by using specific CT findings with emphasis on transmesenteric hernia. Radiology 2001; 221:422-8. [4] Callander C, Rusk R, Nemir A. Mechanism, symptoms and treatment of hernia into the descending mesocolon (left duodenal hernia). Surg Gynecol Obstet 1935;60:1052-71. [5] Manji R, Warnock GL. Left paraduodenal hernia: an unusual cause of small-bowel obastruction. Canadian J Surg 2001;44:455-7. [6] Kurachi K, Nakamura T, Hayashi T, et al. Left paraduodenal hernia in an adult complicated by ascending colon cancer: a case report. World J Gastroenterol 2006;12:1795-7.