Diagnostic Images of the Transmesenteric Hernia:
A Case Report
影像診斷腸繫膜疝氣：病例討論
Shu-Hsiang Wang, Wei-Ching Lin, Yung-Jen Ho, Yung-Fang Chen, Chien-Hung Lin, Yu-Fen Chiu
Department of Radiology, China Medical University Hospital, Taichung
王舒香，林維卿，何永仁，陳永芳，林建宏，邱裕芬
中國醫藥大學附設醫院放射線部
★ Introduction
An internal hernia means the protrusion of a viscus through a congenital or
pathogenic aperture and into a compartment in the abdominal cavity.
Transmesenteric hernia accounts for 5-10% of all internal hernias. [1][2]
We present a rare case of 56-year-old male without past history of previous surgery or abdominal trauma and diagnosed as transmesentric hernia by
preoperatively MDCT.
★ Key words
Internal hernia, transmesenteric, MDCT
★ Clinical Presentation
A 56-year-old man without a history of surgery or abdominal trauma history
presented with sudden onset of epigastric dull pain for several hours. Short of breath and cold sweating also developed. Physical examination revealed
rebounding pain and muscle guarding. Leukocytosis with left shift (WBC: 10790/ul, Seg: 80.6%) was noted. Mild elevated total bilirubun (1.49 mg/dl) with normal Alk p-tase, amylase, lipase and troponin–I were also noted.
★ Image Study
Plain films revealed no dilated bowel loops or intraperitoneal free air.
Sonogram showed gallstones with mild swelling of gallbladder wall.
Computed tomography (CT) showed some cluster of dilated, unopacified, fluid filled small bowel loops with mural thickening and relatively poor
enhancement were incidentally found. There were two small bowel loops with a beak like appearance and blurred mesenteric vessels converge radically
toward one point. There was small amount of ascites. Closed loops obstruction of small bowel was highly suspected. (Figure 1)
★ Management and Treatment
Emergent operation was performed for possible ischemic change of small
bowel.
The patient received laparotomy later. A segment of small bowel protruding into a defect in the mesentery near the Treitz ligament with congestive
change and no peristalsis were noted. Segmental resection with end-to-end anatomosis and repair of the defect in mensentery were done.
★ Follow-up
The patient was discharged one week later with well-healed wound and no
complication. After discharge, he returned for follow-up in our clinics once per week for one month with no episode of internal hernia.
★ Discussion
Hernias account for approximately 10% of all cases and are the third leading
cause of intestinal obstruction. [3] 0.6% to 5.8% of cases with small bowel obstruction caused by congenital and acquired internal hernias. [4] In all internal hernias, transmesenteric hernia accounts for 5-10%. [1][2] 65% of
this kind of internal hernia occurred at adults. [5][6] Most of the adult patients have past history of previous surgery, abdominal trauma or intraperitoneal
inflammation. [1] However, our patient has no past history of previous surgery abdominal, abdominal trauma neither repetitive obstructive symptom such as nausea, vomiting or abdominal pain.
Clinical symptoms, physical examination and lab data showed nonspecific findings. In the images of CT, there is a segment of small intestine showing a beak sign at two points, which could be defined as a closed loop. And
sac-like clustering of the intestine was also noted. These findings indicated
internal hernia. [7] Blurred mesenteric vessels converge radically toward one point. In addition, blurred converging mesenteric vessels plays an important role in diagnosis of transmesenteric hernia. [8]
The defects of this kind of internal hernia are often near the ligament of
Treitz or the ileocecal valve. It is rather small and absent of a hernial sac. In our patient, the defect was near the ligament of Treitz. Since the defect is
often rather small, the incidence of strangulation and intestinal gangrene is relatively high. The mortality rate of patients treated with or without surgery is 50% to 100%, respectively. [1] In our patient, segmental resection of the non-viable part of small bowel was also performed. He got well after the surgery without any complications. It is due to early diagnosis via MDCT that promote early surgical intervention.
Operative management includes reduction of herniated bowel loops with
resection of the non-viable segments. The defect of internal hernia should be closed after reduction and resection was completed to prevent recurrent
internal hernia. The goals of the operative management are to diagnose and resolve the source of obstruction, resect the nonviable segment and minimize the possibility of an incidental enterotomy. [9] Assessment may be particularly challenging when relief of incarcerated segments of bowel loops without
resection.
Transmesenteric hernia mostly developed after surgeries. The incidence of transmesenteric hernia in patients without history of operation and related to congenital mesenteric defect as a sequela of ischemia as we presented
above is rare. However, this diagnosis should always be kept in mind. When the patient had nonspecific symptoms, signs and laboratory data, computed tomography would be a excellent tool for surveying. The earlier we
diagnosed, the less possibility of complications occurred.
★ Reference
1. Mock CJ, HE Jr: Strangulated internal hernia associated with trauma. Arch Surg 1958;77:881–886.
2. Hansmann GH, Morton SA: Intra-abdominal hernia. Report of a case and review of the literature. Arch Surg 1939; 39:973–986.
3. Kendrick ML: Partial small bowel obstruction: clinical issues and recent technical advances. Abdom Imaging. 2009; 34(3):329.
4. Newsom BD, Kukora JS: Congenital and acquired internal hernias: unusual causes of small bowel obstruction. Am J Surg. 1986; 152 (3): 279.
5. Pennell TC, Shaffner LS: Congenital internal hernia. Surg Clin North Am 1971; 51:1355–1359.
6. Murphy DA: Internal hernias in infancy and childhood. Surgery 1964; 55:311– 315.
7. Norio Hongo, Hiromu Mori, Shunro Matsumoto, Yuriko Okino, Ryo Takaji, Eiji Komatsu: Internal hernias after abdominal surgeries: MDCT features. Abdom Imaging (2011) 36:349–362
8. Nobuyuki Takeyama, Takehiko Gokan, Yoshimitsu Ohgiya,Shuichi Satoh, Takashi Hashizume, Kiyoshi Hataya, Hiroshi Kushiro, Makoto Nakanishi,
Mitsuo Kusano, Hirotsugu Munechika: CT of internal hernias. RadioGraphics 2005; 25:997–1015
9. Scott-Conner, CEH. Emterolysis for intestinal obstruction. In Chassin’s Operatvie Strategy in General Surgery, 3rd ed, Scott-Conner, CEH (Ed), Springer, New York 2002. p.337.
Figure 1. Axial (a-1, a-2), coronal (a-3) CT revealed cluster of small bowel loops (dotted line) transited through mesenteric defect (curve line).
Note the closely apposed afferent (Al), efferent (El) loops and
accompany vessels also transited through mesenteric defect.
