Statistics from Altmetric.com
- Internal hernia
- paraduodenal hernia
- small bowel obstruction
- abdominal pain
- abdominal surgery
- small intestine
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).
What is your possible diagnosis?
See page 1001 for the 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.
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
Competing interests None.
Patient consent Obtained.
Provenance and peer review Not commissioned; not externally peer review.
If you wish to reuse any or all of this article please use the link below which will take you to the Copyright Clearance Center’s RightsLink service. You will be able to get a quick price and instant permission to reuse the content in many different ways.