Closed-loop small bowel obstruction-internal hernia

Case contributed by Dr Ammar Ashraf

Presentation

Severe colicky abdominal (periumbilical) pain & vomiting for 2 days and constipation for 1 day. Past history of laparoscopic biliopancreatic diversion (BPD) surgery, laparoscopic cholecystectomy and open appendectomy.

Patient Data

Age: 45 years
Gender: Male

A few mildly dilated small bowel loops with multiple air fluid levels are seen. No pneumoperitoneum is seen.  A few surgical clips are seen in the epigastrium and right hypochondrium.

Changes of previous biliopancreatic diversion surgery are seen. 

Dilated oral contrast filled jejunal loops measuring 3-4 cm are seen in the left lumbar region. No oral contrast passage is seen in the distal small bowel. Mildly dilated fluid-filled ileal loops are seen clustered in the right lumbar region. Two distinct transition points located next to each other, mesenteric edema/inter-loop fluid, and a whirl sign are appreciable along these dilated ileal loops in the right lumbar region.  No pneumatosis or pneumoperitoneum is seen. A small amount of free fluid is seen around the liver. No oral contrast leakage/extravasation is seen. 
A hyperdense focus is seen in supra-renal abdominal inferior vena cava (inferior vena cava filter with probable surrounding thrombus). Enlarged azygous vein and multiple collaterals are seen in the abdominal cavity as well as in the subcutaneous soft tissues of the abdominal wall; these findings are suggestive of chronic inferior vena cava thrombosis (likely as a complication of IVC filter or a complication of previous bariatric surgery). Average size kidneys with multiple peripheral small subcentimeter hyperdense cysts (average density=70-90 HU), which are likely hemorrhagic cysts (hyperdense renal cysts). A simple cortical cyst is also seen in either kidney. 

CONCLUSION: The above mentioned CT findings are suggestive of closed-loop small bowel obstruction secondary to internal hernia (related to previous surgical interventions); another possibility can be adhesions. The possibility of small bowel ischemia cannot be excluded from this unenhanced examination (IV contrast not administered due to high creatinine).

Case Discussion

The patient underwent emergent laparoscopy, converted into the open laparotomy.

OPERATIVE FINDINGS: A big defect was seen in the mesentery in the right lumbar region. Herniation and 180 degrees twisting of the common alimentary limb along with anastomosis was noted through this mesenteric defect. The herniated small bowel was congested, hyperemic, edematous but viable. The hernia was reduced, the torsion was detorted, and the normal anatomy of the small bowel was restored. The mesenteric defect was closed.

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Case information

rID: 78439
Published: 4th Jun 2020
Last edited: 7th Jun 2020
Inclusion in quiz mode: Included
Institution: King Abdulaziz Hospital Al Ahsa (MNGHA)

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