University of California Irvine Digestive Health Institute Orange, CA
Sophie Trujillo, DO, Nathan Park, MD, Jaclyn Heliman, MD, Nimisha Parekh, MD University of California Irvine Digestive Health Institute, Orange, CA
Introduction: The incidence of internal hernias is < 1% and accounts for 0.5-5.8% of all cases of intestinal obstruction. Transomental internal hernias (TIH) are rare, accounting for 1-4% of all internal hernias. TIH do not have a hernia sac and present as a small bowel herniation through an omental defect.
Case Description/Methods: 51 year old female with a diagnosis of Ulcerative Colitis in 2011 who underwent total proctocolectomy with ileal pouch anal anastomosis in 2016 complicated by Crohn’s like disease of the pouch in 2018. She is currently on Ustekinumab with endoscopic healing. Surgical history is notable for a ventral hernia repair with mesh in 2016, total abdominal hysterectomy with bilateral salpingectomy for uterine fibroids in 2017, obesity with a prior gastric sleeve in 2020. She presented to the hospital with acute abdominal pain and obstipation.
Her vitals were stable. CBC with mild leukocytosis of 13.6. CMP and lactate was normal. Abdominal CT showed an internal hernia of the distal ileum, likely transmesenteric, with swirling of the mesentery suspicious for volvulus and low-grade partial obstruction at proximal and distal transition points. Oral contrast noted to have reached IPAA.
She was initially treated conservatively and started on a clear liquid diet but developed recurrent severe abdominal pain a few hours later. An abdominal radiograph on day two showed small bowel loop in the left upper quadrant measuring up to 8.7 cm.
A diagnostic laparoscopy was performed and revealed a proximal small bowel limb presumably at the site of the previous small bowel anastomosis with herniation through the gastrohepatic ligament with tethering over the gastric remnant. The small bowel was reduced through this hernia defect. The herniated bowel loop appeared dilated, but without ischemic changes. The decision was made to not repair the gastrohepaticligament, as it may compromise potential blood supply to the remnant. Post-operatively, the patient was significantly better and tolerated a diet.
Discussion: TIH are a rare subtype of internal hernia and can cause intestinal obstruction. The most common cause of TIH are iatrogenic, resulting from prior surgical interventions. TIH frequently presents with small bowel strangulation with an associated high morbidity and mortality. Thus, there must be a high index of suspicion to prevent delays in diagnosis and management. Abdominal CT is the first-line imaging. Surgical exploration is needed to confirm the diagnosis, evaluate the bowel, and treat.
Figure: CT abd/pelvis showing an internal hernia of the distal ileum, likely transmesenteric, with swirling of the mesentery suspicious for volvulus and low-grade partial obstruction at proximal and distal transition points.
Disclosures:
Sophie Trujillo indicated no relevant financial relationships.
Nathan Park indicated no relevant financial relationships.
Jaclyn Heliman indicated no relevant financial relationships.
Nimisha Parekh indicated no relevant financial relationships.
Sophie Trujillo, DO, Nathan Park, MD, Jaclyn Heliman, MD, Nimisha Parekh, MD. P4997 - The Swirl Sign: An Unusual Case of Obstruction, ACG 2024 Annual Scientific Meeting Abstracts. Philadelphia, PA: American College of Gastroenterology.
