Computerized Medical Imaging and Graphics 29 (2005) 459–461 www.elsevier.com/locate/compmedimag
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Transient left paraduodenal hernia Gulgun Yilmaz Ovali*, Sebnem Orguc, Murat Unlu, Yuksel Pabuscu ¨ g˘. U ¨ yesi, 45010 Manisa, Turkey Department of Radiology, Medical Faculty, Celal Bayar University, Radyoloji O Received 30 June 2004; revised 1 September 2004; accepted 1 September 2004
Abstract A 52-year-old woman with acute deterioration of recurrent abdominal pain was admitted to the hospital. Spiral computed tomography (CT) of abdomen was performed. A left paraduodenal hernia was identified on CT. There was no clinical sign or imaging finding suggesting intestinal obstruction or mesenteric ischemia. She refused surgical intervention since her pain was intermittant and decreasing. On the fifth day of hospitalization the patient’s pain resolved completely and the follow-up CT demonstrated regression of the herniation. q 2005 Elsevier Ltd. All rights reserved. Keywords: Left paraduodenal hernia; CT; Internal hernia; Small bowel; Gastrointestinal tract
In the course of acute abdomen internal hernia is an important and underdiagnosed condition. Paraduodenal hernias are the most common type of internal abdominal hernias, accounting for over one-half of reported cases [1]. Radiographically, left paraduodenal hernias present as an ovoid conglomeration of jejunal loops in the left upper quadrant, often displacing the adjacent organs [2]. Clinical symptoms range from totally asymptomatic to chronic or acute bowel obstruction. In this report we present the CT findings of a left paraduodenal hernia which has spontaneously regressed within a week.
1. Case report A 52-year-old woman presented with acute recurrent abdominal pain, nausea, and emesis. When she was hospitalized three years ago, ultrasonography, gastroscopy and colonoscopy were performed and they were unremarkable. No further evaluation of the patient was done, since her findings resolved spontaneously. At this presentation clinical examination showed tenderness in the left upper abdomen. Spiral CT was performed
after oral and intravenous (iv.) administration of nonionic contrast material. The patient received 100 ml of iomeprol (Iomeron, 300/100) contrast medium intravenously, amidotrizoic acid (Urovideo 75%) orally. On CT an ovoid conglomeration of jejunal bowel loops was seen between the transverse colon and the stomach. This cluster of mildly dilated small bowel loops seemed encasing in a sac and lied to the left of the ligament of Treitz (Fig. 1). With these findings the diagnosis was established as left paraduodenal hernia. The engorged mesenteric vessels that supply the herniated small bowel segments were crowded together towards the entrance of the hernia sac and thus created a whirl-oriented pattern (Fig. 2). The mesentery showed heterogeneous increase of density. No bowel wall thickening, pneumatosis or hemorrhage was detected. There was no clinical sign or imaging finding suggesting intestinal obstruction or mesenteric ischemia. The patient refused surgical intervention since her pain was intermittant and decreasing. On the fifth day of hospitalization, the patient’s pain resolved completely and the follow-up CT demonstrated regression of the herniation (Fig. 3). The whirl-like pattern and the heterogenity of the mesentery decreased and the engorgement of superior mesenteric artery and vein disappeared (Fig. 4).
* Corresponding author. Tel.: C90 236 2349070; fax: C90 236 2370213. E-mail addresses: gul
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2. Discussion
0895-6111/$ - see front matter q 2005 Elsevier Ltd. All rights reserved. doi:10.1016/j.compmedimag.2004.09.019
Paraduodenal hernias are the most common type of internal abdominal hernias, accounting for over one-half of
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G.Y. Ovali et al. / Computerized Medical Imaging and Graphics 29 (2005) 459–461
Fig. 3. Regression of the hernia sac on follow-up CT. Fig. 1. Herniated small bowel loops in the left upper quadrant.
reported cases [1]. Paraduodenal hernias are usually left sided; 75% occur on the left, while 25% occur on the right side [3]. The paraduodenal fossa (fossa of Landzert) is the only fossa to the left of the duodenum capable of developing into the sac of a hernia. The herniated small bowel loops may become trapped within this mesenteric sac [4]. Recognition of the inferior mesenteric vein is useful because it is the most important landmark of the duodenojejunal junction. It runs superiorly along the right margin within the descending mesocolon and joins the splenic vein or superior mesenteric vein at the transverse mesocolon—small bowel mesentery junction. CT can clearly demonstrate an encapsulated bowel loop that displaces the inferior mesenteric vein anteriorly, suggesting that the trapped loop is located behind the descending mesocolon [5]. Herniation of bowel loops through mesenteric defects can also be a transient or intermittent phenomenon that can
Fig. 2. The engorged mesenteric vessels towards the entrance of the hernia sac.
further confound the diagnosis. Clinical or radiographic studies performed during asymptomatic intervals are likely to reveal no abnormality [6]. The clinical manifestations result from partial or complete obstruction of the small intestine, which occurs in 50% of cases [5]. We believe that paraduodenal hernia should be suspected in patients with chronic, atypical abdominal pain, regardless of the findings for small bowel obstruction. Knowledge and recognition of internal hernias are important, since they are prone to strangulation and potentially lethal. With bowel obstruction the mortality rate is expected to be as high as 20% [7]. Surgical intervention is recommended as soon as the diagnosis is established. Because of the fact that preoperative diagnosis of left paraduodenal hernias can only be done by radiographic examination the radiologist should be familiar with all of the sometimes subtle diagnostic features.
Fig. 4. Regression of the engorged mesenteric vessels on follow-up CT.
G.Y. Ovali et al. / Computerized Medical Imaging and Graphics 29 (2005) 459–461
In the radiology literature, Williams described the first roentgen findings of intra-abdominal hernias in 1952 [8]. CT features were described by many authors such as Schaffler, Warshaver and Mauro [9]. They all described the entrapment of small bowel loops and the engorgement and displacement of the mesenteric vessels [8,9]. Meyers reported spontaneous regressing of internal hernias in 1970 [1]. All the authors comment on that the diagnostic work-up of paraduodenal hernias by CT gives us adequate information. Either the trapment of small bowel loops and the typical displacement of mesenteric vessels are well described by CT. As the radiographic diagnosis depends on the time of imaging, it is very important to diagnose the hernia radiologically on time. There are reports about spontaneous regressing of hernias in the literature but there is no report of showing the imaging findings regressing. In this report we present the CT findings of a left paraduodenal hernia which has spontaneously regressed within a week. We named this case as ‘transient left paraduodenal hernia’.
3. Summary A 52-year-old woman with acute deterioration of recurrent abdominal pain was admitted to the hospital. Spiral computed tomography (CT) of abdomen was performed. A left paraduodenal hernia was identified on CT. Paraduodenal hernias are the most common type of internal abdominal hernias, accounting for over one-half of reported cases. Clinical symptoms range from totally asymptomatic to chronic or acute bowel obstruction. She refused surgical intervention and follow up CT was performed. The follow-up CT demonstrated regression of the herniation. As the spontaneous regression was mentioned in the literature, we showed the regression by CT and named this case as ‘transient left paraduodenal hernia’.
References [1] Meyers MA. Paraduodenal hernias. In: Meyers MA, editor. Dynamic radiology of the abdomen; normal and pathologic anatomy. 2nd ed. New York, NY: Springer; 1982. p. 121–8.
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[2] Gore RM, Levine MS. Textbook of gastrointestinal radiology. 2nd ed. Philadelphia: WB Saunders Company; 1994. p. 2382–400. [3] Suchato C, Pekanan P, Panjapiyakul C. CT findings in symptomatic left paraduodenal hernia. Abdom Imaging 1996;21:148–9. [4] Blachar A, Federle MP. Internal hernia: clinical and imaging findings in 17 patients with emphasis on CT criteria. Radiology 2001;218: 68–74. [5] Okino Y, Kiyosue H. Root of the small bowel mesentery: correlative anatomy and CT features of pathologic conditions. Radiographics 2001;21:1475–90. [6] Day DL, Drake DG. CT findings in left paraduodenal hernia. Gastrointest Radiol 1988;13:27–9. [7] Passas V, Karavias D, Grilias D, Birbas A. Computed tomography of left paraduodenal hernia. J Comput Assist Tomogr 1986;10:542–3. [8] Williams AJ. Roentgen diagnosis of intraabdominal hernia. An evaluation of roentgen findings. Radiology 1952;59:817–25. [9] Schaffler GJ, Groell R. Anterior and upward displacement of the inferior mesenteric vein: a new diagnostic clue to left paraduodenal hernias? Abdom Imaging 1999;24:29–31.
Gulgun Yilmaz Ovali, MD was graduated from Ege University Medical Faculty in I˙zmir at 1997. She has got her radiology fellowship from Radiology Department of Celal Bayar University Medical Faculty in 2002. She is still working in Celal Bayar University as a radiology specialist.
Sebnem Orguc, MD was graduated from Ege University Medical Faculty in I˙zmir at 1989. She has got her radiology fellowship from Radiology Department of Ege University Medical Faculty in 1995. She has worked in a private imaging department between 1995 and 2002. She is working as a radiology specialist in Celal Bayar University.
Murat Unlu, MD was graduated from Ege University Medical Faculty in I˙zmir at 1999. He has got his radiology fellowship from Radiology Department of Celal Bayar University Medical Faculty in 2004.
Yuksel Pabuscu has got his MD degree from Medical Faculty of Gu¨lhane Military Medical Academy at 1983. He has completed his radiology fellowship in 1989. He worked as associated professor of Radiology in Gu¨lhane Military Medical Academy untill 2002. Professor Pabuscu is working as the chief of Radiology Department of Celal Bayar University Medical Faculty since 2002.
