Presentation
A known case of peptic ulcer disease, presented with acute epigastric pain radiating to the back. Guarding in the same region on examination, not improving with analgesia - ?perforation from peptic ulcer.
Patient Data
Small bowel loops appear clustered and positioned in the left anterior pararenal space, located posterior to the inferior mesenteric vein and ascending branch of the left colic artery.
The right side is largely devoid of small bowel loops. This is compatible with left para duodenal internal herniation.
Mild mesenteric fat stranding and congestion are noted at the site of hernia.
Bowel wall enhancement is normal with no evidence of bowel ischemia. No bowel obstruction.
No free fluid or free gas is seen in the abdomen and pelvis.
Large bowel appears unremarkable.
Uterus is greatly enlarged presumably due to multiple fibroids.
Urinary bladder is moderate to grossly distended and deviates to the left iliac fossa due to enlarged uterus.
Case Discussion
Left para-duodenal hernia is more common than right and is due to herniation of small bowel loops through the fossa of Landzert, a congenital failure of fusion of the descending colon mesentery to the peritoneum in the left upper quadrant.
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