Presentation
Central abdominal pain and tenderness. Previous appendectomy.
Patient Data
Borderline distended loop of small bowel within the left abdomen, but without multiple air fluid levels on the erect projection is equivocal for early/partial small bowel obstruction. Proximal colonic fecal loading noted. No free intra-peritoneal gas demonstrated.
"Sac-like" configuration of jejunum in the left upper quadrant with dilated small bowel with fecalization. Associated small bowel mesenteric fat stranding. No free gas.
Normal appearance of the colon. Appendix not identified. Single calcified intra-abdominal lymph node.
Case Discussion
The patient proceeded to laparotomy, which confirmed the transmesenteric internal hernia. On imaging, the differential diagnosis is a left paraduodenal hernia but these are located more superiorly between the pancreas and stomach. The other possibility is prolapsed bowel under an adhesion. In adults, prior surgery, trauma or inflammation are the most common causes of transmesenteric hernias - this patient has had a prior appendectomy