CASE 5120 Published on 12.08.2006

Paraduodenal hernia

Section

Abdominal imaging

Case Type

Clinical Cases

Authors

Voultsinou D., Krikis P., Voultsinos V ., Adoniou A.. Palladas P.

Patient

75 years, male

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Clinical History

Male 75 years old presented with repeated episodes of illeus. On clinical examination of the abdomen there was abdominal tenderness and generalized abdominal pain combatable with acute abdomen. The abdominal pain initiated before two days with loss of appetite and vomits.

Imaging Findings

A 75 years old male with a free history evaluated for acute abdomen. The abdominal pain was generalized. On clinical examination of the abdomen there was abdominal tenderness and generalized abdominal pain combatable with acute abdomen. The abdominal pain initiated before two days with loss of appetite and vomits. The patient underwent ultrasound and computed tomography examination. The ultrasound examination was normal and CT scan revealed an engorged, stretched, and displaced mesenteric vascular pedicle and of converging vessels at an orifice between the pancreas and the stomach (the hernia orifice fossa of Landzert) (Figure 1,2). The mesenteric vasculature and the second part of the duodenum were normal.

Discussion

There are two main types of hernias, external and internal. While external hernias refer to prolapse of intestinal loops through a defect in the wall of the abdomen or pelvis, internal hernias are defined by the protrusion of a viscus through a normal or abnormal peritoneal or mesenteric aperture within the confines of the peritoneal cavity. The orifice can be either acquired, such as a post surgical, traumatic or post-inflammatory defect, or can be congenital, including both normal apertures, such as the foramen of Winslow and pathological apertures arising from anomalies of internal rotation and peritoneal attachment. Within the broad category of internal hernias, there are several main types, as traditionally described by Meyers, based on location. Specifically, these consist of paraduodenal (53%), pericecal (13%), foramen of Winslow (8%), transmesenteric/ transmesocolic (8%), intersigmoid (6%) and retroanastomotic (5%), with the overall incidence of internal hernias between 0.2-0.9%, they comprise up to 5.8% of all small bowel obstructions, which, if left untreated, have been reported to have an overall mortality exceeding 50% if strangulation is present. Over the last decade, their incidence is increasing due to the more frequent performance of liver transplantations and gastric bypass surgery (for bariatric treatment). In this subset of patients, internal hernias account for just over half of all cases of small bowel obstruction, almost equal to those caused by adhesions in one study. Without a heightened awareness they can often be misdiagnosed, with subsequent significant morbidity and mortality. Computed tomography plays an important role in diagnosis of acute intestinal obstruction and planning of surgical treatment. The diagnosis of internal hernias is based on observation of a saclike mass or cluster of dilated small bowel loops at an abnormal anatomic site or observation of an engorged, stretched, and displaced mesenteric vascular pedicle and of converging vessels at the hernial orifice.

Differential Diagnosis List

Left paraduodenal hernia

Final Diagnosis

Left paraduodenal hernia

References

[1] Inoue Y, Shibata T, Ishida T. CT of internal hernia through a peritoneal defect of the pouch of Douglas. AJR Am J Roentgenol 2002; 179:13051306. (PMID: 12388518)

[2] Hoeffel JC, Zimberger J, Pocard B, Hoeffel C. Demonstration by computed tomography of a case of internal small bowel herniation. Br J Radiol 1992; 65:10451046. (PMID: 1450823)

[3] Nobuyuki Takeyama, MD, Takehiko Gokan, MD, Yoshimitsu Ohgiya, MD, Shuichi Satoh, MD, Takashi Hashizume, MD, Kiyoshi Hataya, MD, Hiroshi Kushiro, MD, Makoto Nakanishi, MD, Mitsuo Kusano, MD and Hirotsugu Munechika, MD.CT of Internal Hernias. RadioGraphics 2005;25:997-1015. (PMID: 16009820)

Case information

URL:	https://eurorad.org/case/5120
DOI:	10.1594/EURORAD/CASE.5120
ISSN:	1563-4086

Figure 1

CT scan revealed an engorged, stretched, and displaced mesenteric vascular pedicle and of converging vessels at an orifice between the pancreas and the stomach (the hernia orifice fossa of Landzert)

Figure 2

CT scan shows a saclike mass of jejunal loops between the pancreatic head and stomach. The descending mesocolon and stomach are displaced laterally. (fossa of Landzertl)