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Emergency management of an uncommon abdominal pain
  1. Chia-Hung Lu1,2,
  2. Tung-Cheng Chang3,4,
  3. Pen-Shen Lai3,4,
  4. Hong-Jen Hsieh1,2,
  5. Kao-Lang Liu1
  1. 1Department of Medical Imaging, National Taiwan University Hospital, National Taiwan University College of Medicine, Taipei, Taiwan
  2. 2Department of Medical Imaging, National Taiwan University Hospital Yun-Lin Branch, Yun-Lin, Taiwan
  3. 3Department of Surgery, National Taiwan University Hospital, National Taiwan University College of Medicine, Taipei, Taiwan
  4. 4Department of Surgery, National Taiwan University Hospital Yun-Lin Branch, Yun-Lin, Taiwan
  1. Correspondence to Dr Kao-Lang Liu, Department of Medical Imaging, National Taiwan University Hospital and National Taiwan University College of Medicine, No. 7, Chung-Shan South Road, Taipei, Taiwan; lkl{at}ntu.edu.tw

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Clinical presentation

A 69-year-old man with medical history of hypercholesterolaemia presented to our emergency department with a 1-day history of abdominal pain. The pain was neither related to eating nor affected by position. There was no recent change in bowel habit. He was haemodynamically stable, but a palpable left abdominal mass was noted. Laboratory tests were within normal limits. An erect abdominal radiograph suggested small bowel loops clustered in the left side of abdomen (figure 1) but because of diagnostic uncertainty an urgent computed tomography (CT) scan was performed within 3 h on the same day (figure 2).

Figure 1

According to clinical presentation, a radiograph of the abdomen revealed a circumscribed mass shadow due to encapsulated small bowel loops in the left abdomen (arrows).

Figure 2

Computed tomography (CT) scans in axial (A) and coronal (B) planes showed encapsulated bowel loops in the left abdomen.

Question

What is your possible diagnosis?

See page 1001 for the answer.

Answer

From the question on page 925

After correlation with the patient's clinical physical examination, the abdominal radiograph suggested a circumscribed mass shadow due to encapsulated small-bowel loops in the left abdomen but the film was still non-specific to make a diagnosis. Emergency computed tomography (CT) scans on the same day demonstrated sac-like small bowel loops encapsulated in the left abdomen, with anterior displacement of the inferior mesenteric vein (figure 1). A left paraduodenal hernia was suspected. The patient underwent an urgent exploratory laparotomy, which confirmed the diagnosis. He was discharged from hospital on post-operative day 7 after an uneventful recovery.

Figure 1

CT scans in oblique axial (A) and oblique coronal maximum intensity projection (MIP) (B) reformations showed the anterior displacement of the inferior mesenteric vein (IMV) by the encapsulated jejunal loops.

Left paraduodenal hernia is the most common type (40% of all cases) of internal hernia; it occurs when bowels prolapse through the Landzert fossa, located behind the fourth part of the duodenum, into the left portion of the transverse mesocolon and descending mesocolon.1 (figure 2) The Landzert fossa is an aperture present in approximately 2% of the population. Clinically, patients often present with postprandial pain. Once a paraduodenal hernia is identified, operative treatment is necessary, as there is a 50% lifetime risk of obstruction.2 Occlusive symptoms with rapid progression to strangulation may occur; the mortality rate has been reported to be as high as 75% if strangulation is present.3

Figure 2

Graphic illustration of a left paraduodenal hernia depicted loop of small bowel prolapsing (curved arrow) through Landzert's fossa, located behind inferior mesenteric vein and ascending left colic artery (straight arrow). Herniated bowel loops were therefore located lateral to fourth portion of duodenum (from reference 1 with permission).

References

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Footnotes

  • Competing interests None.

  • Patient consent Obtained.

  • Provenance and peer review Not commissioned; not externally peer review.

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