Presentation
Abdominal distension, pain and emesis.
Patient Data
Mildly dilated proximal small bowel loops with air-fluid levels and small bowel fecal sign in addition to the abrupt collapse of the small bowel with twisting/swirling of the mesentery and an apparent internal hernia defect seen at the level of the L2 vertebra and inferior to the level of the pancreas. Moderate amount of free fluid. Changes of post-gastric bypass and cholecystectomy are noted.
A small splenic hypodense lesion is seen which could be a cyst. Hepatomegaly.
Radiological findings compatible with mechanical small bowel obstruction due to an internal hernia.
Case Discussion
The diagnosis of an internal hernia was confirmed by the surgical team.
Internal hernias due to gastric bypass surgery are more common after laparoscopic gastric bypass than after an open procedure. There are three potential sites for internal hernia formation:
- at the defect in the transverse mesocolon
- at the mesenteric defect at the enteroenterostomy
- behind the Roux limb mesentery placed in a retrocolic or antecolic position (retrocolic Petersen and antecolic Petersen)
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