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CASE REPORT
Year : 2015  |  Volume : 3  |  Issue : 3  |  Page : 79-81

Acute intestinal obstruction secondary to left paraduodenal hernia: A case report and literature review


Department of General Surgery, King Khalid Hospital, Hail, Saudi Arabia

Date of Web Publication14-Mar-2016

Correspondence Address:
Dr. Alaa Mohamed Sedik
Department of General Surgery, King Khalid Hospital, Hail
Saudi Arabia
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/2320-3846.178679

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  Abstract 

An internal hernia is a protrusion of bowel through a normal or abnormal orifice in the peritoneum or mesentery. Although they are considered a rare cause (1%) of small intestinal obstruction. Paraduodenal hernias are the most common type of congenital hernias. They constitute a protrusion of bowel into an orifice near the third and fourth portion of the duodenum. The lifetime risk of obstruction and bowel strangulation is around 50% with a mortality of 20% and higher. Despite the rarity of the disease, it poses a serious surgical problem. The high risk of obstruction and the associated mortality mandate repair once the diagnosis is established. High index of suspicion and preoperative imaging are essential to make an early diagnosis to improve outcome.

Keywords: Congenital, internal hernia, intestinal obstruction, paraduodenal hernia


How to cite this article:
Sedik AM, Abdelbar E. Acute intestinal obstruction secondary to left paraduodenal hernia: A case report and literature review. Saudi Surg J 2015;3:79-81

How to cite this URL:
Sedik AM, Abdelbar E. Acute intestinal obstruction secondary to left paraduodenal hernia: A case report and literature review. Saudi Surg J [serial online] 2015 [cited 2019 Sep 22];3:79-81. Available from: http://www.saudisurgj.org/text.asp?2015/3/3/79/178679


  Introduction Top


Paraduodenal hernias are uncommon and they are the most common type of intra-abdominal hernias accounting for half of reported cases. Para duodenal hernias occur more commonly on the left side than on the right .They are associated with a high lifetime risk of causing obstruction, and in cases that present with obstruction, the mortality rate is up to 20%, probably due to a delay in diagnosis. The diagnosis should be considered when examining a patient with acute small bowel obstruction without a history of prior abdominal surgery. CT scan is the method of choice for diagnosing paraduodenal hernia of small bowel loops. If diagnosed, the herniated loops should be reduced and the hernia orifice either closed or widened. [1]

In this article we report a 24-year old man with obstruction symptoms due to left para-duodenal hernia.


  Case Report Top


A 24-year-old Saudi male presented to the emergency room with a 1-day history of acute central abdominal pain not associated with vomiting. He passed a normal motion the day before presentation. There was no jaundice or nor upper or lower gastrointestinal bleeding. The patient stated that he had mild similar attack before 6 months, but he improved spontaneously. He is known to be alcoholic. On presentation, he was in pain, leaning forward in bed, afebrile, with normal heart rate and blood pressure. Her abdomen was diffusely tender with guarding. A suprapubic bulge could hardly be felt as he was uncooperative. He had exaggerated bowel sounds. His blood works including serum amylase came to be normal. Plain X-ray of the abdomen was not conclusive, and ultrasonography showed a minimal pelvic collection. Computerized tomography (CT) intravenous contrast as patient refused to take oral dye showed clustered loops of small bowel in [Figure 1] and pancreas looked normal. After informed consent, the patient was taken to theater for exploratory laparotomy. The abdomen was entered through a midline incision; a large peritoneal sac was found, with most of the small bowel inside the sac with a distal ileum outside. Serosanguineous fluid found both inside and outside the sac with its orifice looking to the right. The inferior mesenteric vein was running at its border.
Figure 1: Plain X-ray of the abdomen (a) was not conclusive but computed tomography scan (b) of the abdomen showed a cluster of small bowel loops


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Omentum and transverse colon were now retracted cephalad and left paraduodenal hernia was instantly visible to the left of the duodenojejunal junction [Figure 2].
Figure 2: (a) The sac after laparotomy. (b) Reducing the sac contents with congested loops of bowel and after enlarging the orifice of the sac. (c) The sac was opened completely before removing the excess


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Small bowel that had herniated underneath the inferior mesenteric vein through the paraduodenal fossa into the retroperitoneal space was now easily reduced after enlarging the hernial orifice in avascular area. The bowel initially appeared dusky and decompressed but was found to be fully viable after several minutes. The excess sac was excised, and the remaining was plicated to avoid recurrence. The abdomen was closed and a drain left in the pelvis. He did well and tolerated oral feeding and passed motion normally. On the fifth postoperative day, he experienced mild central abdominal pain, but he maintained normal vital signs and his abdominal examination was unremarkable except for mild central tenderness. His blood works showed mild attack of pancreatitis and was managed conservatively. The drain removed on the 7 th day. He was discharged on the 10 th postoperative day in a good general condition. He was seen twice in the outpatient department was doing fine with wound and returned to full activity.


  Discussion Top


Internal hernias may be either congenital or acquired. Meyers classified internal hernias based on their location as paraduodenal, transmesenteric, pericecal, transmesosigmoid, perivesical supravesical, etc. [5] Internal hernias are an uncommon cause of small bowel obstruction with a reported incidence of 0.2-0.9% [6] with paraduodenal hernia being the most common entity half of the time (M:F = 3:1). [5] Literature review between 1980 and 2012 using PubMed revealed only 44 case reports [2],[3],[5] Left paraduodenal hernia involves fossa of Landzert located lateral to the fourth portion of the duodenum to the left side and posterior to the inferior mesenteric vein and left colic artery. It is present as a congenital defect in 2% of population. Right paraduodenal hernia involves fossa of Waldeyer located inferior to the third part of duodenum and posterior to superior mesenteric artery and right colic vein. Left paraduodenal hernias (75%) are more common than right para-duo hernias (25%). The diagnosis of paraduodenal hernia is almost never achieved clinically. [4],[8] Patients usually present with abdominal pain, vomiting, and abdominal distension. They give history of recurrent vague and general abdominal symptoms. Plain erect X-ray abdomen may shows air fluid levels like any other case of intestinal obstruction. Barium studies, CT and magnetic resonance imaging show the presence of clustered and well-circumscribed loops of small bowel in an abnormal location. The patient should be prepared for emergency laparotomy with initial resuscitation and nasogastric decompression. Intraoperatively, bowel loops are seen herniating into the orifice. The contents of internal hernia are reduced slowly taking care of the surrounding vital structures such as vessels which form the boundaries of hernial orifices. If any segment of bowel is necrosed, ischemic or perforated, resection, and anastomosis should be done. Enlargement of the orifice for the reduction of contents should be withheld as it involves risk of injuring vessels. The hernia orifice should be closed to prevent recurrences with nonabsorbable sutures or mesh. [8],[9] Repair of the paraduodenal hernia can also be done through laparoscopy. [9]

Median age at presentation was 47 (range of 18-82 years old) with male to female ratio of 3:1. In this review, patients often presented with symptoms and signs of typical of internal hernias complicated by bowel obstruction, strangulation, and/or necrosis. Besides, 43% of patients reported a prior history of recurring abdominal pain with symptoms. Only three cases presented with a palpable mass in the left upper quadrant at time of presentation.


  Conclusion Top


Although paraduodenal hernia is a rare cause of small bowel obstruction, one should consider this diagnosis if a patient presents with symptoms of intestinal obstruction without any previous history of laparotomies or in the absence of any inflammatory pathology. The diagnosis of an internal hernia should be borne in mind when there is a previous history of recurrent pain abdomen with vague abdominal symptoms and clinical features of acute intestinal obstruction. A thorough knowledge of the anatomy and boundaries of various peritoneal fossae is required to reduce the postoperative morbidity and mortality. [6],[7]

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
  References Top

1.
Blachar A, Federle MP, Dodson SF. Internal hernia: Clinical and imaging findings in 17 patients with emphasis on CT criteria. Radiology 2001;218:68-74.  Back to cited text no. 1
    
2.
Olzabal A, Guasch I, Casas D. Case report: CT diagnosis of non-obstructive left paraduodenal hernia. Clin Radiol 1992;46:288-9.  Back to cited text no. 2
    
3.
Martin LC, Merkle EM, Thompson WM. Review of internal hernias: Radiographic and clinical findings. AJR Am J Roentgenol 2006;186:703-17.  Back to cited text no. 3
    
4.
Khalaileh A, Schlager A, Bala M, Abu-Gazala S, Elazary R, Rivkind AI, et al. Left laparoscopic paraduodenal hernia repair. Surg Endosc 2010;24:1486-9.  Back to cited text no. 4
    
5.
Borscheid R, Shah S. Left paraduodenal hernia: Case report and literature review. Eur J Surg Sci 2011;2:62-7.  Back to cited text no. 5
    
6.
Virich G, Davies W. A massive left paraduodenal fossa hernia as an unusual cause of small bowel obstruction. Ann R Coll Surg Engl 2010;92:W7-9.  Back to cited text no. 6
    
7.
Brehm V, Smithuis R, Doornebosch PG. A left paraduodenal hernia causing acute bowel obstruction: A case report. Acta Chir Belg 2006;106:436-7.  Back to cited text no. 7
    
8.
Bartlett MK, Wang C, Williams WH. The surgical management of paraduodenal hernia. Ann Surg 1968;168:249-54.  Back to cited text no. 8
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9.
Palanivelu C, Rangarajan M, Jategaonkar PA, Anand NV, Senthilkumar K. Laparoscopic management of paraduodenal hernias: Mesh and mesh-less repairs. A report of four cases. Hernia 2008;12:649-53.  Back to cited text no. 9
    


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