A rare cause of intestinal obstruction: right paraduodenal hernia

ABSTRACT

Internal herniation is an extremely rare cause of intestinal obstruction. Paraduodenal hernias result from abnormal rotation of the bowel. Symptoms that may range from recurrent abdominal pain to acute obstruction may occur. If it is not diagnosed and treated in time, the disease may result in intestinal ischemia. This article aimed to present the diagnosis and treatment process of a 47-year-old male presenting with acute abdomen symptoms by evaluating retrospectively with the accompaniment of literature. During the abdominal exploration of the patient, nearly all of the intestines were observed to be herniated from the right paraduodenal region to the posterior area. The opening of the hernial sac was repaired primarily by reducing the intestinal bowel loops into the intraperitoneal region. The patient undergoing anastomosis by performing resection of the ischemic part after reduction of herniated bowel loops was discharged uneventfully on the post-operative 10th day. Paraduodenal hernia is a condition that should be considered in patients with abdominal pain and intestinal obstruction symptoms. Early diagnosis is of vital importance to prevent the complications which can develop.

INTRODUCTION

An internal herniation is defined as herniation of the small intestine loops through a mesenteric defect within the abdominal cavity.[1] Internal hernia is a rare cause of acute abdomen and may lead to intestinal obstruction and ischemia if it is not diagnosed and treated in time.[2,3] The right PDH is less frequently seen. It is observed in males three times more commonly than in females, and it is most commonly seen in the fourth and sixth decades of life.[1,2] During a lifetime, approximately half of the patients carry a risk of intestinal obstruction or strangulation.[2] This article aims to present a 47-year-old male undergoing surgery due to a right paraduodenal hernia.

CASE REPORT

A 47-year-old male patient who presented in the emergency department with complaints of abdominal pain and vomiting was hospitalized at the clinic with a preliminary diagnosis of bowel obstruction. During the presentation, the patient’s blood pressure, pulse rate, and temperature were measured to be 135/80 mmHg, 94/min, and 38.7°C, respectively. At the physical examination, there was widespread defense and rebound in all abdominal quadrants. Decompression through a nasogastric tube and intravenous fluid replacement were planned. The leukocyte count was 10930/mm³, the blood glucose level was 474 mg/dL, and other biochemical values were within normal limits. Clustered bowel loops were observed in the right upper quadrant of the computed tomography (Fig. 1). A laparotomy was performed on the patient due to an acute abdomen. On exploration at laparotomy, all of the small bowel loops except some parts of the terminal ileum were observed to have herniated posteriorly through an opening in the right paraduodenal region, and the mesentery was partially twisted (Fig. 2). Most of the small bowel loops were observed to be ischemic (Fig. 3). The small bowel loops were reduced by manual traction. Necrotic, small bowel loops were resected. An end-to-end anastomosis was performed between the proximal portion of the jejunumapproximately 100 cm distal to the ligament of Treitz, and the distal portion of the ileum approximately 40 cm distal to the terminal ileum. The defect was primarily repaired, and the operation was terminated. The post-operative period of the patient was uneventful, and he was discharged on the post-operative 10th day. It was considered to be extensive ischemic necrosis during the histopathological investigation. He had no complaints during the 8th-month post-operative follow-up, and his physical examination was evaluated to be within normal limits.

Figure 1.

The appearence on the computarized tomography scan.

Figure 2.

Most of the small bowel loops encapsulated within the hernia sac.

Figure 3.

Necrotic small bowel loops.

Written informed consent was obtained from the patient for the publication of the case report and the accompanying images.

DISCUSSION

Paraduodenal hernias are among the rare causes of intestinal obstruction. One percent of all small bowel obstructions result from internal herniation.[1,3] Paraduodenal hernias account for 53% of all patients with intestinal obstruction.[3] They may be acquired associated with intestinal resection or congenital due to embryonic malrotation of the midgut or an incomplete union of mesoepithelium during organogenesis. Since our patient had no history of abdominal surgery, the patient was considered to have a congenital right paraduodenal hernia.

Twenty-five percent of paraduodenal hernias are seen on the right side. When the literature knowledge was investigated, <50 cases of right paraduodenal hernia were reported until today. Furthermore, in our study, bowel herniation through Waldeyer’s fossa on the right side (which is rarely seen) was detected.

It can be seen three times more commonly in males than in females.[1] Although it can be seen at each age, it is most commonly seen in the fourth and sixth decades of life.[1-5] Furthermore, our patient was male and in the fourth decade of life.

While the clinical course of the disease is asymptomatic in half of patients, the remaining half may have symptoms such as abdominal pain, nausea, vomiting, distension, inability to pass flatus, and stool developing due to ileus resulting from recurrent cramp-like abdominal pains or torsion. The severity of symptoms in patients is defined by the degree of obstruction. The symptoms were severe in our patients due to ischemia.

Imaging methods play an essential role in the diagnosis. With its higher rate of accuracy, abdominal computed tomography is the most critical non-invasive radiological imaging method that will accelerate the treatment process with its role in identifying the diagnosis, severity, and etiology of the disease.

At computed tomography, small bowel loops in the left paraduodenal hernia can be determined as clustering with abnormal localization behind the stomach and at the left side of the fourth portion of the duodenum or in the vicinity of the pancreas tail. In the right paraduodenal hernia, the clustering of dilated small bowel segments as if in a sac is a characteristic finding.

The treatment is surgical. Open surgery is commonly preferred, but a laparoscopic approach has also been performed in recent years.[6-8] The basic principle of treatment is a surgical procedure based on the reduction of herniated bowel loops and the primary repair of the defect.[7] The surgery that will be performed may differ according to delays in diagnosis. If there is no ischemia finding and the reduction of incarcerated small bowel loops is necessary, resection of the hernia sac and repair of the defect are recommended. A delay in diagnosis may cause an acute clinical picture that can result in incarceration and intestinal necrosis. In cases of the development of ischemia and necrosis in small bowel walls, resection of bowel loops may be necessary. The mortality rate in cases developing necrosis is higher than 50%.[8-10] Furthermore, in our patient, necrosis was determined in the majority of small bowels, but mortality did not develop.

CONCLUSION

When a mechanical bowel obstruction is detected, internal herniation should be considered in patients without previous abdominal surgery. Considering the delay in diagnosis and treatment will considerably increase morbidity and mortality, early surgical treatment should be performed as fast as possible.