Abstract
We present the case of a 46-year-old man admitted with acute abdominal pain with no obvious cause despite simple investigations. Further imaging revealed a rare transomental internal hernia. At exploratory laparotomy, the hernia was released, no bowel resection was required and the patient was discharged 2 days later.
Keywords: Transomental internal hernia, Acute abdominal pain
Case history
A 46-year-old man was admitted via the emergency department with sudden onset, left-sided, sharp, abdominal pain that had awoken him from sleep. Two days previously, he had a similar episode of abdominal pain that resolved upon bowel opening. He had no other symptoms and had an unremarkable past medical history. On examination, he was distressed and in pain, but had a soft, non-distended abdomen. There was mild tenderness in the left iliac fossa on deep palpation, but nothing else of note. The bowel sounds were normal. Besides a minor leucocytosis, all preliminary investigations, including arterial blood gases, were reported normal. He remained haemodynamically stable throughout. However, his pain was significantly out of proportion to the clinical findings and the results of initial investigations. An unenhanced computed tomography (CT) scan of the abdomen was performed (Fig. 1).
Figure 1.
Unenhanced CT sections of the mid-abdomen in a craniocaudal direction.
Discussion
Figure 1 is a composite image of a series of unenhanced CT sections in a craniocaudal direction. They demonstrate a distend loop of small bowel in a ‘C’ shape lying under the left anterior abdominal wall (image 5). The mesenteric vessels leading to this loop can be seen to be converging. There is loss of sharpness of these vessels with haziness of the fatty tissue surrounding them (images 1–4). The convergence of the vessels infers the presence of a defect through which this loop has herniated creating a ‘closed loop’ obstruction and the haziness is indicative of vascular compromise.
Investigative laparoscopy revealed, blood-stained fluid with multiple distended loops of small bowel. At exploratory laparotomy (Fig. 2), a congested, but viable, ileal loop was found, herniating through the greater omentum. The herniation was released and the omental defect and abdomen closed. The patient was discharged 2 days later.
Figure 2.
Internal hernial orifice in the greater omentum.
Internal hernias have an autopsy incidence of 0.2–0.9%.1 Transomental (greater or lesser) are rarer still accounting for less than 1% of all internal hernias and are usually a complication of previous surgical procedures.2–4 Small bowel obstruction secondary to an internal hernia is a surgical emergency. Whilst abdominal radiographs and ultrasonography may be of some diagnostic use, CT scanning remains the gold standard.3,5
Conclusions
This case promotes the consideration and early recognition of internal herniae as a cause of abdominal pain in patients presenting to the emergency department. Despite the rarity of transomental internal herniae, the importance of its recognition as a possible cause of an acute surgical abdomen should never be forgotten.
References
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