Presentation
Acute onset upper abdominal pain. Peritonism. Previous diverticulitis.
Patient Data
Mild focal stranding/fluid adjacent to the proximal descending colon in the setting of several diverticula. There is an encapsulated cluster of small bowel loops within the left upper quadrant between the stomach and left kidney, converging to a central mesenteric point medially, posterior to the inferior mesenteric vein. The stomach and D-J flexure are displaced anteriorly. Mild vessel engorgement and mesenteric fat-stranding within the hernia. Trace of free fluid within the inferior aspect of the cluster. The low mono E recons demonstrates mild reduction in small bowel wall enhancement within the involved bowel loops. The small bowel loops are not distended. No free gas or pneumatosis. Mild pelvic free fluid within the pelvis.
Unremarkable appearance of the liver, gallbladder, and pancreas. Horseshoe kidney with unchanged marked left renal pelvis dilation. Prominent vascular calcification at the splenic hilum. Left adrenal low-density nodule (unchanged over 5 years).
Impression
Clustered partially encapsulated small bowel loops in the left upper quadrant suggestive of a small bowel internal hernia (possibly a left paraduodenal hernia based on location). Mild hypoenhancement of the involved small bowel loops raise the concern for ischemia. No small bowel distension. No pneumoperitoneum or pneumatosis.
Mild focal paracolic stranding adjacent to the proximal descending colon with background diverticular disease.
Case Discussion
The patient underwent laparoscopy which identified:
60 cm of proximal small bowel herniated into a hernial sac to the left of the DJ flexure
fibrosed opening of the sac opened up to widen the aperture with minor surrounding adhesiolysis required
all of the small bowel were reduced and viable
The patient had an uneventful recovery.
Left paraduodenal hernia is the most common internal hernia. If the small bowel is sufficiently mobile, it can pass through the developmental defect which lies inferior to the duodenojejunal flexure and posterior to the inferior mesenteric vein and the ascending branch of the left colic artery. The herniated bowel is contained by peritoneal membrane in the fossa of Landzert and the herniated bowel has an encapsulated appearance. These hernias may present with positional post-prandial pain or obstruction. The lifetime risk of infarction is around 50% 1.
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