Document Detail

Acute intestinal obstruction secondary to left paraduodenal hernia: a case report and literature review.
Jump to Full Text
MedLine Citation:
PMID:  23324390     Owner:  NLM     Status:  PubMed-not-MEDLINE    
Abstract/OtherAbstract:
INTRODUCTION: An internal hernia is a protrusion of bowel through a normal or abnormal orifice in the peritoneum or mesentery. Although they are considered as a rare cause of intestinal obstruction, paraduodenal hernias are the most common type of congenital hernias.
METHODS: A literature search using PubMed was performed to identify all published cases of left paraduodenal hernia (LPDH).
RESULTS: In Literature search between 1980 and 2012 using PubMed revealed only 44 case reports before the present one. Median age was 47 years (range 18 - 82 years). Nearly 50% reported previous mild symptoms. Two-third of patients required emergency surgery in form of laparotomy or laparoscopic repair. Reduction of hernia contents with widening or suture repair of the hernia orifice were the most common standards in surgical management of LPDH.
CONCLUSION: Intestinal obstruction secondary to internal hernias is a rare presentation. High index of suspicion and preoperative imaging are essential to make an early diagnosis in order to improve outcome.
Authors:
Waleed Al-Khyatt; Smeer Aggarwal; James Birchall; Tomothy E Rowlands
Publication Detail:
Type:  Journal Article     Date:  2013-01-16
Journal Detail:
Title:  World journal of emergency surgery : WJES     Volume:  8     ISSN:  1749-7922     ISO Abbreviation:  World J Emerg Surg     Publication Date:  2013  
Date Detail:
Created Date:  2013-01-23     Completed Date:  2013-01-24     Revised Date:  2013-04-05    
Medline Journal Info:
Nlm Unique ID:  101266603     Medline TA:  World J Emerg Surg     Country:  England    
Other Details:
Languages:  eng     Pagination:  5     Citation Subset:  -    
Affiliation:
Division of General Surgery and Radiology, Royal Derby Hospital, Uttoxetter Road, Derby DE22 3DT, UK. mzxwa@nottingham.ac.uk.
Export Citation:
APA/MLA Format     Download EndNote     Download BibTex
MeSH Terms
Descriptor/Qualifier:
Comments/Corrections

From MEDLINE®/PubMed®, a database of the U.S. National Library of Medicine

Full Text
Journal Information
Journal ID (nlm-ta): World J Emerg Surg
Journal ID (iso-abbrev): World J Emerg Surg
ISSN: 1749-7922
Publisher: BioMed Central
Article Information
Download PDF
Copyright ©2013 Al-Khyatt et al.; licensee BioMed Central Ltd.
open-access:
Received Day: 24 Month: 9 Year: 2012
Accepted Day: 14 Month: 1 Year: 2013
collection publication date: Year: 2013
Electronic publication date: Day: 16 Month: 1 Year: 2013
Volume: 8First Page: 5 Last Page: 5
PubMed Id: 23324390
ID: 3551681
Publisher Id: 1749-7922-8-5
DOI: 10.1186/1749-7922-8-5

Acute intestinal obstruction secondary to left paraduodenal hernia: a case report and literature review
Waleed Al-Khyatt12 Email: mzxwa@nottingham.ac.uk
Smeer Aggarwal1 Email: smeer.aggarwal@gmail.com
James Birchall1 Email: james.birchall@nhs.net
Tomothy E Rowlands1 Email: timrowlands@hotmail.com
1Division of General Surgery and Radiology, Royal Derby Hospital, Uttoxetter Road, Derby DE22 3DT, UK
2Division of Surgery, School of Graduate Entry Medicine and Health, University of Nottingham, Royal Derby Hospital, Uttoxeter Road, Derby, DE22 3DT, UK

Introduction

Internal hernia is, either congenital or acquired, a rare cause of small-bowel obstruction, with a reported incidence of less than 2% [1]. Paraduodenal hernias, which are a type of internal hernia, occur due to malrotation of midgut and form a potential space near the ligament of Treitz [2]. Incidental finding at laparotomy or on imaging is the most common presentation of these hernias [3]. Nevertheless, Paraduodenal hernias can lead to bowel obstruction, ischemia, and perforation with a high mortality. Left paraduodenal hernia (LPDH) is the most common types of congenital hernias and accounts for more than 40% of all cases [4]. Clinical diagnosis of LPDH is a real challenge as symptoms are entirely nonspecific. Therefore, a timely and correct diagnosis with a rapid diagnostic tool is mandatory [5]. In this review we discuss the clinical presentation and management of small bowel obstruction secondary to LPDH.


Case presentation

A 47 –year-old Caucasian male admitted with increasing severe colicky abdominal pain and bile stained vomiting of 2 days duration. He had no previous significant past medical or surgical history. He also denied any history of weight loss, or recent changes in his bowel habit. However, He described at least 4 previous episodes of upper abdominal distension and vomiting with spontaneous resolution over the previous 2 years. On examination, the patient appeared in moderate pain with normal vital signs. Abdominal examination revealed abdominal distension with a tender mass in the left upper quadrant. Laboratory studies were essentially normal. An urgent abdominal CT scan confirmed the diagnosis of small bowel obstruction secondary to what looked like a hernia into the left paraduodenal fossa (fossa of Landzert) (Figure  1). At laparotomy, a hernia sac of 25 cm in diameter arising from a defect just to the left of the fourth part of the duodenum was found, consistent with a LPDH (Figure  2A). The intestinal loops were herniated through that congenital defect and were not spontaneously reducible. A band containing the inferior mesenteric vein was deemed necessary to divide at the time in order to widen the orifice of the defect and to retrieve the dilated small bowel from the hernia sac (Figure  2B). The hernia sac was excised completely down to the base at the mesentery of large bowel (Figure  2C). The patient had uneventful postoperative recovery and discharged home 5 days later. At 8 weeks post-surgery, he was back to full normal activities with a well-healed laparotomy scar.


Discussion

Internal herniation of the small bowel is a relatively rare cause of intestinal obstruction and accounts for less than 2% of all causes [1]. Among all congenital hernias, paraduodenal hernias are the most common type with an overall incidence of approximately 50% of all internal hernias [1,4,6]. LPDH (hernia of Lanzert) is about three times more common than the right counterpart (Waldayer’s hernia) [7]. LPDH arises from the fossa of Landzert, a congenital defect which presents in approximately 2% of the population, located to the left of the fourth part of the duodenum, posterior to the inferior mesenteric vein and left branches of the middle colic artery (Figure  2A) [2,8,9]. Small bowel loops (usually jujenum) prolapse posteroinferiorly through the fossa to the left of the fourth part of the duodenum into the left portion of the transverse mesocolon. Hence, the herniated small bowel loops may become trapped within this mesenteric sac (Figure  2C) [4,10].

Literature search between 1980 and 2012 using PubMed revealed only 44 case reports before the present one [2,5,11-49] (Table  1). Median age at presentation was 47 (range of 18–82 years old) with male to female ratio of 3:1. In this review, patients often presented with symptoms and signs of typical of internal hernias complicated by bowel obstruction, strangulation, and/or necrosis. Besides, 43% of patients reported a prior history of recurring abdominal pain with symptoms. Only three cases presented with a palpable mass in the left upper quadrant at time of presentation.

Radiological diagnosis of LPDH prior to surgery was achieved in 43% of patients. On CT scan, typical appearance of LPDH is an encapsulated sac containing clusters of dilated small bowel loops at or above the ligament of Treitz with a mass like effect compressing the posterior gastric wall and distal part of the duodenum. Besides, there is engorgement and crowding of the mesenteric vessels with frequent right displacement of the main mesenteric trunk and depression of the transverse colon (Figure  1).

Once a LPDH is identified, operative treatment is necessary, as patients with a LPDH have a 50% lifetime risk of developing small bowel obstruction with a 20–50% mortality rate for acute presentations [6,8]. In this review, 28 patients (67%) underwent emergency surgery. Of those 43 patients, 15 patients had laparoscopic repair of LPDH. Surgical intervention included reduction of the herniated small bowel loops and closure of the hernia orifice with non-absorbable sutures or a mesh [5,24]. A different possibility was to widen the hernia orifice to prevent future incarceration of bowel loops [5]. Often, there is a close anatomical relationship between the inferior mesenteric vein which bound the hernia anteriorly, and the hernia orifice [5,24]. Therefore, division of the inferior mesenteric vessels at the neck of the sac may be necessary, as in this case, when the incarcerated bowel could not be reduced easily from the hernia [24].


Conclusion

Left paraduodenal fossa hernia is a relatively a rare cause of small bowel obstruction. In young patients with recurrent small bowel obstruction with no previous surgical history, it is crucial to consider internal hernias in the differential diagnosis. Furthermore, a timely and correct diagnosis is together with prompt surgical intervention is essential for achieving patient’s cure and prevents future complications.


Consent

Written informed consent was obtained from the patient for publication of this case report and accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal.


Competing interests

The authors declare that they have no competing interests.


Authors’ contributions

WAK, SA, JB, and TER prepared the manuscript. TER outlined the manuscript’s layout and supervised the work. All authors read and approved the final manuscript.


References
Blachar A,Federle MP,Dodson SF,Internal hernia: clinical and imaging findings in 17 patients with emphasis on CT criteriaRadiologyYear: 20012181687411152781
Berardi RS,Paraduodenal herniasSurg Gynecol ObstetYear: 19811521991107006131
Olazabal A,Guasch I,Casas D,Case report: CT diagnosis of nonobstructive left paraduodenal herniaClin RadiolYear: 199246428828910.1016/S0009-9260(05)80175-81424457
Martin LC,Merkle EM,Thompson WM,Review of internal hernias: radiographic and clinical findingsAJR Am J RoentgenolYear: 2006186370371710.2214/AJR.05.064416498098
Khalaileh A,et al. Left laparoscopic paraduodenal hernia repairSurg EndoscYear: 20102461486148910.1007/s00464-009-0794-720054582
Blachar A,et al. Radiologist performance in the diagnosis of internal hernia by using specific CT findings with emphasis on transmesenteric herniaRadiologyYear: 2001221242242810.1148/radiol.221201012611687686
Khan MA,Lo AY,Vande Maele DM,Paraduodenal herniaAm SurgYear: 19986412121812229843350
Zonca P,et al. Treitz's herniaHerniaYear: 200812553153410.1007/s10029-008-0339-318231845
Willwerth BM,Zollinger RM Jr,Izant RJ Jr,Congenital mesocolic (paraduodenal) hernia. Embryologic basis of repairAm J SurgYear: 1974128335836110.1016/0002-9610(74)90173-14412601
Armstrong O,et al. Internal hernias: anatomical basis and clinical relevanceSurg Radiol AnatYear: 200729433333710.1007/s00276-007-0212-617487440
Chatterjee S,Kumar S,Gupta S,Acute intestinal obstruction: a rare aetiologyCase Rep SurgYear: 2012201250120922792504
Hafeez Bhatti AB,Khan MA,Left paraduodenal hernia: a rare cause of large bowel obstruction and gangreneJ Coll Physicians Surg PakYear: 201222425025122482384
Akbulut S,Unusual cause of intestinal obstruction: left paraduodenal herniaCase Report MedYear: 2012201252924622474457
Hussein M,et al. Laparoscopic repair of a left paraduodenal hernia presenting with acute bowel obstruction: report of a caseSurg Laparosc Endosc Percutan TechYear: 2012221e28e3010.1097/SLE.0b013e31823f379822318073
Fernandez-Rey CL,Martinez-Alvarez C,Concejo-Cutoli P,Acute abdomen secondary to left paraduodenal hernia: diagnostic by multislice computer tomographyRev Esp Enferm DigYear: 20111031383921341937
Downes R,Cawich SO,A case of a paraduodenal herniaInt J Surg Case RepYear: 201012192110.1016/j.ijscr.2010.06.00322096667
Parmar BP,Parmar RS,Laparoscopic management of left paraduodenal herniaJ Minim Access SurgYear: 20106412212410.4103/0972-9941.7260121120072
Yun MY,et al. Left paraduodenal hernia presenting with atypical symptomsYonsei Med J51578778920635458
Uchiyama S,et al. An unusual variant of a left paraduodenal hernia diagnosed and treated by laparoscopic surgery: report of a caseSurg TodayYear: 200939653353510.1007/s00595-008-3875-719468812
Poultsides GA,et al. Image of the month. Left paraduodenal herniaArch SurgYear: 2009144328728819289672
Kuzinkovas V,et al. Paraduodenal hernia: a rare cause of abdominal painCan J SurgYear: 2008516E127E12819057724
Peters SA,et al. Radiology for the surgeon: Soft-tissue case 60Can J SurgYear: 200851215115218377758
Jeong GA,et al. Laparoscopic repair of paraduodenal hernia: comparison with conventional open repairSurg Laparosc Endosc Percutan TechYear: 200818661161510.1097/SLE.0b013e318182573319098672
Palanivelu C,et al. Laparoscopic management of paraduodenal hernias: mesh and mesh-less repairs. A report of four casesHerniaYear: 200812664965310.1007/s10029-008-0376-y18465192
Shoji T,et al. Left paraduodenal hernia successfully treated with laparoscopic surgery: a case reportCase Rep GastroenterolYear: 200711717610.1159/00010759521487549
Papaziogas B,et al. Idiopathic hypertrophic pyloric stenosis combined with left paraduodenal hernia in an adultMed Princ PractYear: 200716215115410.1159/00009837017303953
Moon CH,Chung MH,Lin KM,Diagnostic laparoscopy and laparoscopic repair of a left paraduodenal hernia can shorten hospital stayJSLSYear: 2006101909316709368
Brehm V,Smithuis R,Doornebosch PG,A left paraduodenal hernia causing acute bowel obstruction: a case reportActa Chir BelgYear: 2006106443643717017702
Thoma M,et al. Left paraduodenal hernia: a case reportActa Chir BelgYear: 2006106443343517017701
Cingi A,et al. Left-sided paraduodenal hernia: report of a caseSurg TodayYear: 200636765165410.1007/s00595-006-3205-x16794804
Kurachi K,et al. Left paraduodenal hernia in an adult complicated by ascending colon cancer: a case reportWorld J GastroenterolYear: 200612111795179716586557
Huang YM,et al. Left paraduodenal hernia presenting as recurrent small bowel obstructionWorld J GastroenterolYear: 200511416557655916425435
Ovali GY,et al. Transient left paraduodenal herniaComput Med Imaging GraphYear: 200529645946110.1016/j.compmedimag.2004.09.01915994059
Fukunaga M,et al. Laparoscopic surgery for left paraduodenal herniaJ Laparoendosc Adv Surg Tech AYear: 200414211111510.1089/10926420432297390715107222
Rollins MD,Glasgow RE,Left paraduodenal herniaJ Am Coll SurgYear: 2004198349249310.1016/j.jamcollsurg.2003.07.02515008162
Patti R,et al. Paraduodenal hernia: an uncommon cause of recurrent abdominal painG ChirYear: 200425518318615382478
Catalano OA,et al. Internal hernia with volvulus and intussusception: case reportAbdom ImagingYear: 200429216416510.1007/s00261-003-0122-y15290940
Goodney PP,Pindyck F,Paraduodenal hernia and jejunal diverticulosisJ Gastroenterol HepatolYear: 200419222923110.1111/j.1440-1746.2004.02859.x14731138
Tong RS,Sengupta S,Tjandra JJ,Left paraduodenal hernia: case report and review of the literatureANZ J SurgYear: 2002721697110.1046/j.1445-2197.2002.02300.x11906430
Nishida T,et al. Unusual type of left paraduodenal hernia caused by a separated peritoneal membraneJ GastroenterolYear: 200237974274410.1007/s00535020012112375149
Patil R,Smith C,Brown MD,Paraduodenal hernia presenting as unexplained recurrent abdominal painAm J GastroenterolYear: 199994123614361510.1111/j.1572-0241.1999.01617.x10606327
Schaffler GJ,et al. Anterior and upward displacement of the inferior mesenteric vein:a new diagnostic clue to left paraduodenal hernias?Abdom ImagingYear: 1999241293110.1007/s0026199004359933669
Uematsu T,et al. Laparoscopic repair of a paraduodenal herniaSurg EndoscYear: 1998121505210.1007/s0046499005919419303
Hirasaki S,et al. Unusual variant of left paraduodenal hernia herniated into the mesocolic fossa leading to jejunal strangulationJ GastroenterolYear: 199833573473810.1007/s0053500501649773941
McDonagh T,Jelinek GA,Two cases of paraduodenal hernia, a rare internal herniaJ Accid Emerg MedYear: 1996131646810.1136/emj.13.1.648821234
Suchato C,Pekanan P,Panjapiyakul C,CT findings in symptomatic left paraduodenal herniaAbdom ImagingYear: 199621214814910.1007/s0026199000318661761
Warshauer DM,Mauro MA,CT diagnosis of paraduodenal herniaGastrointest RadiolYear: 1992171131510.1007/BF018884981544549
Du Toit DF,Pretorius CF,Left paraduodenal hernia with acute abdominal symptoms. A case reportS Afr Med JYear: 19867042332343738664
Tireli M,Left paraduodenal herniaBr J SurgYear: 198269211410.1002/bjs.18006902197059766

Figures

[Figure ID: F1]
Figure 1 

Axial enhanced CT demonstrates a cluster of dilated jejunal loops located in the Landzert´s fossa.



[Figure ID: F2]
Figure 2 

A)Operative finding of hernia sac in the fossa of Landzert containing small bowel loops.B) Abnormal congenital band (ligament of Treitz) containing inferior mesenteric vein. C) A potential space in the large bowel mesentery (arrow) with hernia sac was laid opened.



Tables
[TableWrap ID: T1] Table 1 

Reported cases of left paraduodenal hernia


Author,year Age(years) Gender Chronic symptoms Small bowel obstruction Left paraduodenal hernia confirmed on imaging Emergency/elective surgery Laparotomy Laparoscopic
Chatterjee et al., 2012 [11]
55
Male
-
Yes
-
Emergency
Yes
-
Bhatti et al., 2012 [12]
18
Female
-
Yes
-
Emergency
Yes
-
Akbulut et al., 2012 [13]
42
Male
-
Yes
-
Emergency
Yes
-
Hussein et al. 2012 [14]
59
Female
-
Yes
Yes
Emergency
-
Yes
Fernandez-Ray et al. 2011 [15]
39
Male
-
Yes
Yes
Emergency
Yes
-
Downes et al., 2010 [16]
47
Male
Yes
-
-
Emergency
Yes
-
Parmar et al.,2010 [17]
38
Male
Yes
-
-
Elective
-
Yes
Khalaileh et al., 2010 [5]
53
Female
-
Yes
Yes
Emergency
-
yes
Yun et al., 2010 [18]
28
Male
-
-
Yes
Emergency
Yes
-
Uchiyam et al., 2009 [19]
80
Female
Yes
-
-
Elective
-
Yes
Poultsides et al., 2009 [20]
67
Female
-
Yes
-
Emergency
-
Yes
Kuzinkovas et al., 2008 [21]
59
Male
-
-
-
Elective
Yes
-
Peters et al., 2008 [22]
76
Male
-
Yes
Yes
Emergency
Yes
-
Jeong et al., 2008 [23]
52
Male
-
Yes
-
Emergency
-
Yes
Jeong et al., 2008 [23]
58
Female
-
Yes
-
Emergency
-
Yes
Palanivelu et al., 2008 [24]
-
Male
-
-
Yes
Elective
-
Yes
Palanivelu et al., 2008 [24]
-
Male
-
Yes
Yes
Emergency
-
Yes
Palanivelu et al., 2008 [24]
-
Female
-
Yes
Yes
Elective
-
Yes
Shoji et al., 2007 [25]
60
Male
-
-
-
Emergency
-
Yes
Papaziogas et al., 2007 [26]
35
Female
-
Yes
-
Emergency
Yes
-
Moon et al., 2006 [27]
18
Male
-
Yes
-
Emergency
-
Yes
Brehm et al. 2006 [28]
54
Female
Yes
-
Yes
Emergency
Yes
-
Thoma et al., 2006 [29]
72
Female
Yes
-
-
Elective
Yes
-
Cingi et al., 2006 [30]
30
Male
Yes
-
-
Emergency
Yes
-
Kurachi et al., 2006 [31]
47
Female
-
Yes
-
Emergency
Yes
-
Huang et al., 2005 [32]
24
Male
Yes
Yes
-
Emergency
Yes
-
Ovali et al., 2005 [33]
52
Female
Yes
-
Yes
Refused surgery
-
-
Fukunaga et al., 2004 [34]
51
Male
Yes
Yes
Yes
Emergency
-
Yes
Rollins et al., 2004 [35]
21
Male
Yes
-
Yes
Elective
-
Yes
Patti et al., 2004 [36]
46
Male
Yes
-
-
Elective
Yes
-
Catalano et al., 2004 [37]
82
Male
-
Yes
Yes
Emergency
Yes
-
Goodney et al., 2004 [38]
75
Male
Yes
-
-
Elective
Yes
-
Tong et al., 2002 [39]
30
Male
Yes
-
-
Elective
Yes
-
Nishida et al., 2001 [40]
47
Male
Yes
-
Yes
Elective
Yes
Yes
Patil et al., 1999 [41]
29
Female
-
-
Yes
Emergency
Yes
-
Schaffler et al., 1999 [42]
26
Male
Yes
-
Yes
Elective
Yes
-
Uematsu et al., 1998 [43]
44
Male
Yes
-
-
Elective
-
Yes
Hirasaki et al., 1998 [44]
28
Female
Yes
-
Yes
Elective
Yes
-
Mcdonagh et al., 1996 [45]
52
Male
-
Yes
-
Emergency
Yes
-
Suchato et al., 1996 [46]
40
Male
-
Yes
-
Emergency
Yes
-
Suchato et al., 1996 [46]
52
Male
Yes
-
-
Emergency
Yes
-
Warshauer et al., 1992 [47]
42
Female
Yes
-
Yes
Elective
Yes
-
Toit et al., 1986 [48]
22
Male
-
Yes
-
Emergency
Yes
-
Tireli et al., 1982 [49] 18 Male - Yes - Emergency Yes -


Article Categories:
  • Review


Previous Document:  Topographic models for predicting malaria vector breeding habitats: potential tools for vector contr...
Next Document:  POLG1 mutations and stroke like episodes: a distinct clinical entity rather than an atypical MELAS s...