Petersen hernia

Case contributed by Dr Yair Glick

Presentation

Abdominal pain and nausea without vomiting for a week. The pain worsened on the day of presentation to the ER.

Patient Data

Age: 35 years
Gender: Male
CT

Status post sleeve gastrectomy and Roux-en-Y gastric bypass with antecolic anastomosis.
Small hiatal hernia.
Many signs are suggestive of Petersen hernia: mild fat stranding where the jejunum crosses the transverse colon; the jejunum immediately distal to the Treitz ligament is pulled to the right and slightly swirled; the mesenteric vessels are rotated (whirl sign) with mild mesenteric edema and slightly prominent lymph nodes; most of the small bowel is in the left abdomen and many bowel loops are located anterior to the distal transverse colon.

The abdominal organs (liver, spleen, pancreas, adrenals, and kidneys) are of normal dimensions and appearance.
Retroaortic left renal vein.

Small bilateral fat-containing inguinal hernia.

Case Discussion

Presented to the ER with worsening abdominal pain.
History notable for sleeve gastrectomy performed almost a decade ago, converted to Roux-en-Y gastric bypass half a year ago due to gastroesophageal reflux with mucosal ulcers.
Blood work remarkable only for C-reactive protein of 16 mg/L.
CT abdomen revealed many signs of Petersen hernia, which was laparoscopically verified and corrected:
"Small amount of intra-abdominal chylous fluid found. Signs of chronic partial proximal small bowel obstruction, which was all incarcerated within a Petersen hernia. Closure of mesentery to mesocolon and closure of gastrojejunostomy defect performed."

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