Congenital Left Paraduodenal Hernia Causing Chronic Abdominal Pain and Abdominal Catastrophe

Abstract

Paraduodenal hernias are the most common type of congenital internal hernia. Because of its overall rare incidence, this entity is often overlooked during initial assessment of the patient. Lack of specific diagnostic criteria also makes diagnosis exceedingly difficult, and the resulting diagnostic delays can lead to tragic outcomes for patients. Despite these perceived barriers to timely diagnosis, there may be specific radiographic findings that, when combined with the appropriate constellation of clinical symptoms, would aid in diagnosis. This patient first presented at 8 years of age with vague symptoms of postprandial emesis, chronic abdominal pain, nausea, and syncope. Over the span of 6 years he was evaluated 2 to 3 times a year with similar complaints, all of which quickly resolved spontaneously. He underwent multiple laboratory, imaging, and endoscopic studies, which were nondiagnostic. It was not until he developed signs of a high-grade obstruction and extremis that he was found to have a large left paraduodenal hernia that had volvulized around the superior mesenteric axis. This resulted in the loss of the entire superior mesenteric axis distribution of the small and large intestine and necrosis of the duodenum. In cases of chronic intermittent obstruction without clear etiology, careful attention and consideration should be given to the constellation of symptoms, imaging studies, and potential use of diagnostic laparoscopy. Increased vigilance by primary care and consulting physicians is necessary to detect this rare but readily correctable condition.Internal hernias (IHs) are a rare clinical entity that cause 0.6% to 5.8% of small bowel obstructions. 1 There are 2 broad categories of IH: acquired and congenital. These are further categorized by location, which include paraduodenal, transmesenteric, and supra-or perivesical IHs and those located at the Foramen of Winslow. 2,3 Paraduodenal hernias (PDHs) are thought to be the most common type of congenital IH. 2,3 However, with the increasing incidence of procedures that require Roux-en-Y reconstruction, such as gastric bypass surgery, Kasai, choledochal cyst excision, and pediatric liver transplantation, the incidence of acquired IH is increasing. 4 Left PDH refers to a herniation of the small bowel into a mesenteric defect to the left of the inferior mesenteric vein (IMV) with a hernia sac within the leaflets of the left colon mesentery. 5 Symptoms can range from intermittent partial bowel obstruction in cases of spontaneously reducing IH to acute high-grade obstruction that occurs with incarceration or volvulus. 6 Radiographic diagnosis is made difficult because of the often intermittent nature of the disease, in which spontaneous reduction in and resolution of symptoms can occur by the time diagnostic imaging is performed. 2,7 Even when present, Dr Shi drafted the initial manuscript; Ms Felsted assisted in drafting the initial manuscript; Dr Masand provided radiographic expertise, drafted the figure legends, and reviewed and revised the ma...

Incarcerated left paraduodenal hernia causing small and large bowel obstruction

“…In the literature, to our knowledge, there are few reports which describe left PDH as a cause of large bowel obstruction . In both of these reports, the hernia sac was noted to contain a combination of small bowel and ascending colon, which is similar to the intraoperative findings of our patient .…”

“…In both of these reports, the hernia sac was noted to contain a combination of small bowel and ascending colon, which is similar to the intraoperative findings of our patient . However, either due to the delay in the presentation or diagnosis, both patients in these reports underwent both small and large bowel resections for non‐salvageable bowel ischaemia . In 2014, Shi et al described a patient who developed short gut syndrome and became total parenteral nutrition dependent following extended bowel resection across the entire superior mesenteric artery territory in the setting of a PDH .…”

“…In the literature, to our knowledge, there are few reports which describe left PDH as a cause of large bowel obstruction . In both of these reports, the hernia sac was noted to contain a combination of small bowel and ascending colon, which is similar to the intraoperative findings of our patient . However, either due to the delay in the presentation or diagnosis, both patients in these reports underwent both small and large bowel resections for non‐salvageable bowel ischaemia .…”

“…Internal hernias are unusual cause of small bowel obstruction (SBO) with a reported incidence between 0.6% and 5.8% in the literature . Whilst duodenal recesses are the most common sites for congenital internal herniation, left PDH typically are more common than those on the right .…”

“…However, either due to the delay in the presentation or diagnosis, both patients in these reports underwent both small and large bowel resections for non‐salvageable bowel ischaemia . In 2014, Shi et al described a patient who developed short gut syndrome and became total parenteral nutrition dependent following extended bowel resection across the entire superior mesenteric artery territory in the setting of a PDH . This poor outcome highlights the need for early recognition and prompt surgical intervention to reduce significant morbidity.…”