Closed-loop obstruction due to peritoneal seeding mimicking internal hernia after total gastrectomy
Presentation
History of prior total gastrectomy for gastric cancer, with abdominal pain and PO intolerance since the last month.
Patient Data
Evidence of total gastrectomy and oesophagojejunostomy with roux-en-y reconstruction is visible. A dilated closed-loop of the small bowel is seen in the right upper abdomen. On following the bowel loop, the closed-loop find to be a 25-30 cm part of the Roux limb, about 20 cm from oesophagojejunostomy, and about 5-10 cm proximal to jejunojejunostomy. Considering roux-en-y oesophagojejunostomy and the closed-loop obstruction, an internal hernia was suggested. Mild to moderate ascites and biliary dilation are other findings.
The orange and the yellow arrows depict the proximal and distal end of the closed-loop. The red arrow points the site of Roux-en -y jejunojejunostomy.
Case Discussion
The patient underwent surgery with seven days delay after the admission, because of COVID-19 typical pulmonary infiltrates. On the surgery, the closed-loop was found at the estimated site, but the cause was the peritoneal seeding, not an internal hernia. The seeding was not visible on the CT scan. The ascites could be the only sign of peritoneal seeding, particularly in men and in the absence of pleural effusion and subcutaneous edema.
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