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Congenital internal hernia as a cause of small bowel obstruction: CT findings in 11 adult patients

Departments of ¹ Diagnostic Imaging and ⁴ Surgery "A", Meir Hospital, Sapir Medical Center, Kfar-Saba, and the Departments of Diagnostic Imaging, ² Chaim Sheba Medical Center, Tel Hashomer, Tel Aviv, and ³ Assaf Harofe Medical Center, Zrifin, affiliated to the ⁵ Sackler School of Medicine, Tel-Aviv University, Tel-Aviv, Israel

View larger version (63K): [in a new window]   Figure 1. A 91-year-old man presented with small bowel obstruction (SBO) and diffuse abdominal tenderness. (a) Contrast enhanced CT at the mid abdomen shows a conglomerate of dilated, unopacified, fluid-filled small bowel loops (SB), in the subhepatic region (L=liver), displacing the ascending colon (white arrow) medially. The dilated loops show mural thickening (black arrow) with relative hypoperfusion and adjacent free peritoneal fluid (F), features suggesting strangulation. Dilatation of proximal, opacified small bowel loops is also seen. (b) More caudally, the cluster of dilated small bowel loops with thickened wall is demonstrated adjacent to the right abdominal wall with no overlying omental fat. Engorged and blurred mesenteric vessels, with adjacent mesenteric fluid, are seen converging toward the orifice (arrow) of the hernia sac. A pre-operative CT diagnosis of an incarcerated, strangulated transmesenteric internal hernia was confirmed on surgery. At laparotomy, resection of 50 cm of necrotic jejunum with end to end anasomosis and repair of the hernia were performed.

View larger version (59K): [in a new window]   Figure 2. A 95-year-old man presented with small bowel obstruction (SBO) and diffuse abdominal tenderness. (a) Contrast enhanced CT at the mid abdomen shows a cluster of dilated, unopacified, fluid-filled small bowel loops (thin black arrows) with converging mesenteric vessles (black arrow), in the left abdomen adjacent to the left abdominal wall with no overlying omental fat, displacing the transverse colon posteriorly (white arrowheads) and medially. The dilated loops show mural thickening with relative hypoperfusion with adjacent mesenteric fluid suggesting strangulation. (b) More caudally, the conglomerate of dilated small bowel loops with a thickened wall, some with the small bowel faeces sign (black arrows), are seen displacing the proximal transverse colon (arrowhead). Blurred and engorged mesenteric vessels are seen, converging toward the orifice of the hernia sac (white arrows) as well as free peritoneal fluid. A pre-operative CT diagnosis of an incarcerated, strangulated transmesenteric internal hernia was confirmed on surgery.

View larger version (132K): [in a new window]   Figure 3. A 76-year-old man presented with small bowel obstruction (SBO). Contrast-enhanced CT at the right lower abdomen shows a saclike mass of unopacified dilated small bowel loops with the small bowel faeces sign (small white arrows) and mesenteric vessels converging toward its orifice (arrowhead). The "sac" is interposed between the anteromedially displaced cecum (C) with the entrance of the terminal ileum (thick white arrow) and the lateral abdominal wall. Proximal dilated opacified loops are seen. At surgery a hernia sac containing 60 cm of viable jejunum was found behind the cecum. The incarcerated bowel was reduced and the hernia orifice was sutured.

View larger version (62K): [in a new window]   Figure 4. A 44-year-old woman presented with small bowel obstruction (SBO) and fever. (a) Contrast-enhanced CT at the right lower abdomen shows a cluster of unopacified dilated small bowel loops (white arrows), medially to the cecum with the terminal ileum (black arrow). Opacified, dilated small bowel loops proximal to the hernia sac are also seen. (b) Lower down, the nature of the saclike mass with the unopacified, dilated small-bowel loops with converging and blurred mesenteric vessels (black arrow), interposed between the laterally displaced cecum and the abdominal wall, is clearly demonstrated. At surgery a paracecal hernia containing a viable closed loop was found and repaired.

View larger version (61K): [in a new window]   Figure 5. A 48-year-old man presented with small bowel obstruction (SBO) due to left paraduodenal hernia. (a) Contrast-enhanced CT at the mid left abdomen demonstrates dilatation of clustered small-bowel loops (small white arrows) with converging mesenteric vessels (white arrow), causing right displacement of the superior mesenteric vessels (arrowhead). Mild left-sided hydronephrosis is also seen, as well as the small bowel faeces sign within the dilated loop (black arrow) (Reprinted with permission [12]). (b) CT section at a lower level shows the cluster of dilated small bowel loops (black arrows) causing asymmetrical bulging of the left abdominal wall. The engorged and crowded mesenteric vessels are seen converging toward the opening of the hernia sac (white arrows). Note the excreted contrast media within the right ureter with its absence on the left side related to the uro-mechanical disturbance (Reprinted with permission [13]). At surgery, a hernia sac, containing viable loops of almost the entire small intestine, was found in the left upper quadrant with the inferior mesenteric vein at its opening. Hernial repair was performed.

View larger version (93K): [in a new window]   Figure 6. An 80-year-old man presented with nausea and vomiting with diffuse abdominal tenderness. (a) Contrast-enhanced CT at the pelvis shows numerous dilated small bowel loops (black arrows) one of them with a transition zone (long white arrow) as well as collapsed distal loops (thick white arrow). (b) 1.3 cm caudally, another transition zone of a dilated loop is seen adjacent to that seen in (a) (white arrow) compatible with an entrapped loop within an internial hernia. (c) At the level of the urinary bladder (B), the thickened-wall of the incarcerated small bowel loop is clearly demonstrated (arrows) with adjacent fluid and mesenteric fat infiltration. At laparotomy, a gangrenous incarcerated ileal loop was found within a paravesical hernia. Small bowel resection with ileo-ileal anastomosis and hernial repair were performed.

View larger version (61K): [in a new window]   Figure 7. A 43-year-old man presented with small bowel obstruction (SBO) and fever with diffuse abdominal tenderness. (a) Contrast enhanced CT at the mid-abdomen shows dilated small bowel loops and engorged and twisted mesenteric vessels (arrow) with a whirl pattern indicating volvulus. (b) More caudally, note the radial distribution of the dilated loops and convergence of engorged mesenteric vessels (arrow) suggesting a closed loop SBO. At laparotomy, viable loops were found within an internal hernia, but its distinct type could not be established. The hernia was repaired.