Presentation
Severe abdominal pain
Patient Data
Distended small bowel seen at level of proximal and distal jejunum with twisted like configuration of the mesentery along with multiple air fluid levels, denoting closed loop obstruction.
Abnormal orientation of the jejunal bowel loops being interposed below and to the right of the second part of the duodenum associated with abnormal position of the duodeno-jejunal junction.
Case Discussion
Two pathologies are emphasized in this case. First is the closed loop nature of small bowel obstruction that requires immediate surgical attention before development of bowel ischemia. The second component is the internal hernia which has subtle signs that need attention from the radiologist.
Laparotomy confirmed the diagnosis of right paraduodenal hernia. Untwisting was done followed by enterostomy and suction to relief the bowel distension.
Possible differential include midgut volvulus yet the normal relation of SMV and SMA and patient age group rendered this possibility to be less likely.
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