Sonographic diagnosis of a perirenal transplant bowel hernia.

Abstract

Sonography has a primary role in the evaluation of a variety of complkations that follow renal trans~ plantation. Specifically, sonography has an important role in the detection of perirenal masses, fluid collections, and hydronephrosis. 1 -5 Hematomas , lymphoceles, seromas, urinomas, and abscesses are well known causes of perirenal transplant masses and their sonographic features have been de· scribed. 1 • 3 • 5 \Ve present a case of small bowel hernia that occurred in proximity to the renal transa plant that had a diagnostic sonographic appearance. REPORT OF A CASEA 36-year-old wonmn wa~ admitted for epigastric pain followed by intermittent vomiting of four hours' duration. The patient had unde rgone a cadaveric renal transplant to the right iliac fossa one month prior to her admission. Her immediate postoperative course was complicated only by serum sickness and her transplant kidney had been functioning well. There was no hematcmesis with the vomitin~ and the patient had a normal bowel movement several hours before the abrupt onset of the abdominal pain. U rinc output had been good. On physical examination she was observed to be in moderate pain with temperature 98.6°F. pulse 80 beats/min, blood pressure 190/ll8, and respirations 16/min. There was modemte epigastric tenderness and diminished bowel sounds. There was no sign of peritoneal irritation. Palpation of the right lower qundrant revealed "a prominent transplant kidney" that wns slightly tender. Stool guaiac test was negative. Pertinent admission laboratory tests revealed creatinine 1. 7 mg!dl, BU N 63 mgf dl, bilirubin 0.1 mg!dl, amylase 131 IU/L, white hlood cell count 12,300!cm 3 , and hematocrit 31 per cent.Flat and upright abdominal radiographs on admission showed no dilated howe!. An abdominal real~tim e sono· graphic examination on the day f<1llowing admission showed a normal gallbladder, liver, and pancreas and smnll.. echo~ genic native kidneys. Ascites was present. A 5 x 5 x 6· em fluid collection containing a loop of peristalsing small howel was identified in the perinephric space anterior to the transplant kidney and a perinephric bowel hernia was diagnosed ( figs. 1 and 2). The diameter of the loop of bowel was less than 3 em and the wall tl1ickness was less than 5 mm. The characteristic appearing valvulae conniventes projecting into the bowel lumen were also seen. An upper CI and small bowel follow-through (SBFT) obtained im-