Closed loop obstruction due to transmesenteric hernia

Case contributed by Yaïr Glick
Diagnosis almost certain


Black(?) vomitus for the past day, epigastric pain.

Patient Data

Age: 85 years
Gender: Female

NGT tip projected onto the gastric bubble.
Dilated loops of small bowel up to 3.6 cm in diameter, mostly in the upper and left abdomen.
Colon devoid of gas and content, except perhaps in the hepatic flexure.
Surgical clips projected in right upper abdomen - status post cholecystectomy, most probably.

Impression: small bowel obstruction.

Dilated loops of proximal small bowel. The transition point anterior to the inferior hepatic margin is actually a small aperture to a transmesenteric hernia sac. The hernia sac contains several dilated small bowel loops in a radial configuration of a closed loop obstruction, with decreased wall enhancement and mesenteric vessel edema - findings highly suspicious for ischemic bowel. The loops of small bowel distal to the efferent loop from the hernia aperture are collapsed, as is the entire colon. Distal to said hernia, there is a loop of collapsed small bowel in an umbilical hernia with no sign of strangulation. There are some gas bubbles in the bowel content in the closed loop, and from the point of the umbilical hernia, what little content there is in the distal ileum is fecalized. Small amount of free intraperitoneal fluid - perihepatic, perisplenic, and pelvic.
The gallbladder has been removed. Mildly dilated intrahepatic bile ducts.
Large lipoma in the proximal ascending colon. Few diverticuli in the distal descending colon and proximal sigmoid colon.

(a) oblique coronal reformation showing the locations of the internal hernia aperture (yellow oval) and the umbilical hernia aperture (between arrowheads)

(b) coronal reformation showing the closed loop obstruction (dashed orange curve) inside the transmesenteric hernia sac

Case Discussion

Stomach contents in the NGT.
Right after the reading radiologist reported the salient findings, the patient was rushed to the OR.
60 cm of gangrenous small bowel were resected and a side-to-side anastomosis was performed. The mesenteric aperture was closed and the abdominal space was irrigated with saline. The omentum was released from the umbilical hernia sac and the redundant sac was removed.

How to use cases

You can use Radiopaedia cases in a variety of ways to help you learn and teach.

Creating your own cases is easy.

Updating… Please wait.

 Unable to process the form. Check for errors and try again.

 Thank you for updating your details.