British Journal of Radiology 75 (2002),783-784 © 2002 The British Institute of Radiology
Abdominal pain and vomiting after gynaecological surgery
Y Tsushima, MD
1
K Kato, MD
2 and
K Endo, MD
3
Departments of 1 Radiology and 2 Obstetrics and Gynecology, Motojima General Hospital, 3-8 Nishi-Honcho, Ohta, Gunma 373-0033 and 3 Department of Diagnostic Radiology and Nuclear Medicine, Gunma University Hospital, 3-39-15 Showa-machi, Maebashi, Gunma 371-0034, Japan
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Introduction
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A 63-year-old woman underwent hysterectomy and para-aortic lymph node dissection up to the root of the superior mesenteric artery (SMA) owing to endometrial carcinoma. She had no past history of serious illness except for endoscopic cholecystectomy for a benign polyp 6 years previously. The post-operative course was initially normal, but 6 days after the operation the patient complained of abdominal pain and distension, followed by nausea and vomiting. On physical examination the abdomen was distended, but no mass lesions were evident. Bowel sounds were normal and there was no evidence of peritonitis. Laboratory studies were of no diagnostic significance. Abdominal ultrasound showed dilatation of the stomach, but was otherwise unremarkable. Contrast enhanced CT of the abdomen (Figure 1
) was subsequently performed.
What do the CT images show? What is the diagnosis?
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Answer
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Abdominal CT demonstrated marked dilatation of the stomach and duodenum, with an encapsulated loop of the proximal jejunum in the right side of the abdomen. A diagnosis of right paraduodenal hernia was made. After 2 weeks of conservative management by intravenous fluid replacement, aspiration via an intestinal tube and other supportive therapy, the patient subsequently made a full recovery. An upper gastrointestinal series (Figure 2) and follow-up CT (not shown) confirmed the presence of a right paraduodenal hernia, although there was no evidence of obstruction at the time of these studies. The patient has remained well and free of symptoms during the last year.
Patients with paraduodenal hernia are frequently asymptomatic and these hernias may be discovered incidentally at laparotomy. The most common presentation is acute obstruction of the small intestine, but the patient may also complain of vague and chronic abdominal pain, due to partial small intestinal obstruction [1, 2]. There have been only two reported cases in which the paraduodenal hernia became symptomatic after laparotomy [2, 3]. In our case, para-aortic lymph node dissection up to the SMA root may have changed anatomical relationships in the upper abdomen, which could have triggered symptoms from the right paraduodenal hernia.
The clinical importance of this entity lies in the significant increase in morbidity and mortality rates that result from a delay in its diagnosis [1]. Upper gastrointestinal barium studies may demonstrate encapsulation of jejunal loop in the right mid abdomen [1, 4–6]. The herniated jejunum may be well demonstrated by CT as in this case [2, 5–7].
Although bowel reduction and surgical obliteration of the hernia defect are usually required [1], full recovery was made after conservative management in this patient. The shortness of the entrapped jejunal loop and the wide opening into the hernial sac were likely to contribute to the full recovery without surgery.
Received for publication December 18, 2000.
Revision received April 3, 2001.
Accepted for publication April 19, 2001.
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References
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Introduction
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