Transmesenteric internal hernia related to urostomy resulting in closed loop obstruction

Case contributed by Michael P Hartung
Diagnosis certain


Acute abdominal pain.

Patient Data

Age: 65 years
Gender: Male

Small effusions. RLQ urostomy and LLQ colostomy. Bilateral percutaneous nephrostomy tubes. Infiltrative bladder cancer. Small ascites. Mild swirling/angulation of mid abdominal vasculature. Abnormal clustering of small bowel in the left mid and upper abdomen with relative hypoenhancement, mesenteric edema, relative dilation with fluid, and radial orientation of vasculature toward the midline. Two adjacent transition points entering and exiting this loop can be reasonably traced on the sagittal reformats. 

Case Discussion

This case provides an example of a surgical internal hernia defect as a result of this patient's colostomy and urostomy (he had a complex history related to bladder cancer and rectal invasion of tumor). The findings of clustered small bowel with mesenteric edema, radially oriented vessels, and relative hypoenhancement are highly indicative of a closed-loop obstruction either from adhesions or internal hernia. It is challenging to see the two adjacent transition points (entering/exiting the closed-loop) on axial and coronal reformats, but they can be reasonably traced out on the sagittal reformats, which emphasizes the importance of using all of your reformats for these challenging cases. 

Operative note summary: "Internal herniation of small bowel under end descending colostomy mesenteric defect created by the blood supply crossing the abdomen towards the urostomy. The bowel was reduced and approximately 45 cm was grossly ischemic and necrotic....

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