Unsual cause of internal hernia (omental) with small bowell obstruction

Clinical History

A 74-year-old male with free history evaluated acute abdomen. Imagining findings, abdominal computed tomography (CT) revealed obstructive illeus, with with a strangulated small intestinal loop.

Imaging Findings

A 74-year-old male with free history evaluated acute abdomen. The patient claimed for an intense pain of acute onset after eating mushrooms. On clinical examination the findings were those of acute abdomen. The laboratory results revealed leucytosis. X ray plain film, demonstrated dilated small bowel loops with normal large bowel compatible findings with obstructive type small bowel illeus (Figure 1). Urgent abdominal computed tomography (CT) performed without peros administration of oral gastrographin due to high obstruction and without intravenous administration of contrast medium to previous allergic shock to penicillin. Dilated small bowel loops, with fluid content and thin wall visualized. Some fluid to air levels visualized (Figure 2). The large bowel loops depicted normal. The findings were compatible with plain films results. A small intestinal loop surrounded by increased amount of fatty tissue, with engorgement of adjacent vessels demonstrated (Figure 3). This intestinal loop was the point of origin of the obstruction. There was not any intraperitoneal free air or fluid. Emergency exploration revealed a segment of congested small-bowel loop herniated through a defect over the greater omentum. Reduction of the bowel loops and division of the omental defect was performed without the need for bowel resection. The patient made an uneventful recovery.

Discussion

Acute abdomen defines a syndrome^1,2 characterized by a sudden onset of severe abdominal pain requiring emergency medical or surgical treatment to minimize morbidity and mortality. Clinical assessment is often difficult^1,2 and physical examination, laboratory and conventional radiographic results can be nonspecific. The differential diagnosis includes an enormous spectrum of disorders. In a review² of 30,000 patients with acute abdomen the observers record 28% of patients to have appendicitis, 9.7% cholecystis, 4.1% small bowel obstruction, 4% acute gynecological disease, 2.9% acute renal colic, 2.5% perforated peptic ulcer and 1.5% diverticulitis. In one third of patients, no cause could determine. Intestinal obstruction (4.1% of acute abdomen cases) is a common abnormality that is usually suspected on the basis of clinical signs and patient history. For many decades the diagnosis was based on conventional radiography findings with sensitivity of 69% and specificity of 57%³. Ct sensitivity of 94-100% and a 90-95% accuracy have been reported. The various cases of small bowel obstruction include extrinsic causes (adhesions, closed loop, strangulation, hernia and extrinsic masses), intrinsic causes (adenocarcinoma, chrons disease, tuberculosis, radiation enteropathy, intramural hemorrhage and intussusception), intraluminal causes (foreign body, benzoar) and intestinal malrotation. Extrinsic masses can be a carcinoid tumor, lymphoma, peritoneal carcinomatosis, appendicitis and diverticulitis. Although internal hernias are uncommon cause of intestinal obstruction, they may be included in the differential diagnosis in the absence of a history of abdominal surgery or trauma.Transomental hernias constitute approximately 1%–4% of all internal hernias. Herniation occurs through a free greater omentum; more commonly, herniation into the lesser sac occurs through the gastrocolic ligament and is less frequent. In the first type, the hernial orifice on the greater omentum is located in the periphery near the free edge and is usually a slitlike opening from 2 to 10 cm in diameter. The cause of the omental defect has not been identified, but it has been suggested that most have a congenital origin, although inflammation, trauma, and circulation may also cause omental perforations. Small bowel loops, the cecum, and the sigmoid colon are involved in this defect. CT findings of internal hernias include evidence of small bowel obstruction, a saclike mass or cluster of dilated small bowel loops at an abnormal anatomic location in the presence of small bowel obstruction; an engorged, stretched, and displaced mesenteric vascular pedicle and converging vessels at the hernial orifice or signs of strangulation, which occurs after closed-loop obstruction In patients suspected to have internal hernias, early surgical intervention may be indicated to reduce the high morbidity and mortality rates. Reduction of the bowel loops and division of the omental defect should be performed with or without bowel resection.  

Differential Diagnosis List

Final Diagnosis

Small bowel obstruction due to interal hernia omental hernia.

URL:	https://eurorad.org/case/5727
DOI:	10.1594/EURORAD/CASE.5727
ISSN:	1563-4086