Presentation
Abdominal pain and vomiting.
Patient Data
Dilated jejunal loops. The dilated loops and superior mesenteric vessels are seen crowded in the left side of the abdomen, inferior to the pancreatic tail. The 3rd and 4th parts of the duodenum are seen in abnormal course. The inferior mesenteric vein is seen draining into the superior mesenteric vein. The dilated small bowel loops are seen posterior to the IMV. The SMA and SMV are patent and well opacified. Dilated loops are well enhancing , suggesting no strangulation. No evidence of perforation or portal venous gas. Mild mesenteric edema is noted. Features are those of small bowel obstruction. The relation of the bowel loops to the IMV suggests left paraduodenal hernia.
Patient refused surgery. Follow up study revealed decreased dilatation of part of the jejunal loops. However, the abnormal course and crowding of jejunal loops and superior mesenteric vessels is still present.
Eventually, patient had the surgery. Surgical feedback, however, was not available.
Case Discussion
The small bowel loops appear aggregated on the left side of the abdomen, with abnormal configuration of the superior mesenteric vessels and mesenteric edema. A closed loop obstruction is noted, with the transition point marking the hernial orifice.
The dilated loops are seen posterior to the inferior mesenteric vein, suggesting a left paraduodenal hernia.
Of note, the inferior mesenteric vein drains into the superior mesenteric vein in this patient, which is an anatomical variant.
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