Right Paraduodenal Hernia as a Cause of Acute Abdominal Pain in the Emergency Department: A Case Report and Review of the Literature

Abstract

Paraduodenal hernias (PDHs) represent an unusual cause of acute abdominal pain in the Emergency Department (ED) and are associated with high morbidity attributable to a challenging clinical and radiological diagnosis, as signs and symptoms mimic other frequent causes of acute abdominal pain. We report a right paraduodenal hernia in a 37-year-old female patient who presented to the ED complaining of abdominal pain located in the right lower abdomen and hypogastrium, accompanied by nausea. During diagnostic work up, the abdominal computed tomography scan revealed the presence of small bowel malrotation with concomitant right paraduodenal hernia. These findings were confirmed intraoperatively. We performed a brief literature review about the clinical manifestations and treatment options of right paraduodenal hernias, which retrieved only 30 articles related to this condition. Prompt diagnosis, radiological or intraoperative, of paraduodenal hernias is crucial because nearly 50% will progress to small bowel obstruction. Therefore, it is essential for every clinician to account for them in the differential diagnosis of acute abdominal pain in the ED.

Keywords: acute abdomen; bowel malrotation; bowel obstruction; internal hernia; laparoscopy; laparotomy.

Figure 1

CT scan on admission: coronal (a) and axial (b) images depict the abnormal position of small bowel loops (in black circle) above the transverse colon (black arrow) and to the right. On axial images (c) the horizontal part of the duodenum (white arrow) is positioned on the right and does not run to the left ventrally from the abdominal aorta and inferior vena cava. (d) Maximum intensity projection (MIP) image reconstruction on the coronal plane shows an abnormal left course of the superior mesenteric vein (black arrowhead). (e) Mesenteric vessel congestion at the site of small bowel herniation. (f) Coronal reformatted image showing a normal appendix (white arrowhead).

Figure 2

Nutcracker phenomenon on initial CT scan. (a) On axial images, the hilar portion of the left renal vein (white arrowhead) is distended as a result of the vein compression between the aorta and the superior mesenteric artery (black arrowhead) (b). Coronal reformatted image showing engorged left gonadal vein (black arrow). (c) Accompanying pelvic varices.

Figure 3

Perioperative findings: (a) small intestine loops on the right of Treitz’s ligament (blue arrow). (b,c). The orifice of the hernia (green arrow). (d) Repositioned hernia and closure of the gap (yellow arrow).

Figure 4

Postoperative abdominal CT. (a,b) Coronal reformatted images depicting no small bowel loops located above and to the right of the transverse colon (white arrow) and malrotated duodenum and jejunum loops on the right side of the abdomen (black arrow). (c) Restoration of the normal course of the superior mesenteric vein (black arrowhead).