Internal Hernia Case Studies

Introduction

Hernia is the protrusion of viscera from their normal anatomical position in another area. Hernias are divided into internal and external. In external hernias the protrusion of the viscus is through a defect of the abdominal wall. Regarding the internal hernias the protrusion is through a defect that is located inside the abdominal cavity. This defect can be congenital or acquired. Congenital defects are created due to some embryological mistake that is made between the 5th and 7th week of embryonic development, during which the rotation of the abdominal organs and the merge of the visceral peritoneum with the parietal in specific locations occur. The acquired defects are created after surgical procedures, injury or inflammation

The symptoms of internal herniation usually point to acute intestinal obstruction. In other cases the patient may refer chronic mild digestive complaints or remain asymptomatic. In case of acute obstruction the patient may complain for abdominal pain, bloating, vomiting, absence of gases and feces. Very rarely a mass of viscera can be palpated. So, there must be a high index of clinical suspicion of internal hernia to every patient, who presents to the emergency department with obstruction clinical features. Incarceration is less common. A detailed patient’s anamnesis is very important, because a previous surgery that could cause an acquired internal hernia like Roux-en-Y, can easily add internal hernia into the differential diagnoses. Furthermore, patients with congenital internal hernias often report a history of chronic, mild, digestive complains and chronic pain or a previous visit to the emergency department because of abdominal pain that was improved with spasmolytics

The content of the hernia is located between the stomach and the pancreas. The hernia content is usually small intestine or omentum and less commonly colon or stomach (9). The dominant theory suggests that the left paraduodenal hernias are formed during embryonic life, because the small intestine is trapped between the mesocolon and the posterior abdominal wall (9) (10). This type of hernia can be asymptomatic, cause chronic pain or be present as acute obstruction or ischemia. The image of the CT could be an encapsulated cluster of small bowel loops between stomach and pancreas, that displaces the stomach and strained mesentery vessels (10). The inferior mesenteric vein and the median colic artery are located anterior and medial to the hernia (11).

Right paraduodenal hernias

Right paraduodenal hernias herniate to the Waldeyer’s fossa, posterior to the superior mesenteric artery and inferior to the third portion of the duodenum. On CT imaging the cluster of small bowel loops will be lateral and superior of the second portion of the duodenum and posterior and lateral of superior mesenteric artery (11).

Pericaecal