A late presentation of a left paraduodenal hernia in an elderly patient admitted in emergency: A case report

Abstract

Small bowel internal hernias (IHs), a rare cause of small bowel occlusion (SBO) and small bowel strangulation, while more commonly seen in young adults, can also affect elderly patients and pose a significant diagnostic challenge due to their nonspecific symptoms. In most cases, laparotomy was used to diagnose IHs. However, multidetector computed tomography (MDCT) is usually the best imaging tool to use in the emergency setting for the diagnosis of IHs. An 83-year-old man was admitted to emergency with acute abdominal pain and a coffee-ground vomitus. The abdominal MDCT showed a clustered-like appearance of proximal jejunal loops at the level of the Treitz ligament with the absence of transit of the medium water-soluble iodine oral contrast agent (Gastrografin). Mesenteric edema was also present with initial suffering of the intestinal wall. A left paraduodenal hernia (LPDH) with strangulation was suspected following the radiological report. The emergency laparotomy revealed about 20 cm of proximal jejunal loops herniated through a 3 cm wide hernia orifice (HO) along the Treitz ligament, at the level of Landzert fossa, located in the confluence of the descending mesocolon, posterior to the inferior mesenteric vein (IMV) and confirming the LPDH. The patient was discharged in good condition some days later. IHs do not have sufficient coverage in literature, especially in cases regarding elderly patients, however, they can be a cause of SBO in people older than 80 years of age. Radiologists and surgeons should be aware of the anatomical aspects of the IHs.

Keywords: Emergency laparotomy; Emergency, Multidetector computed tomography; Internal hernia; Left paraduodenal hernia; Small bowel obstruction.

Fig 1

The MDCT made in emergency. In image (A) clustered jejunal loops near the descending colon are well visible on coronal plane and behind the tail of pancreas; in image (B) the clustered jejunal loops described looked like a sac-like mass with an interruption of the Gastrographin transit in the MDCT carried out 6 hours after the first examination.

Fig 2

The surgical pictures showing in the image (A) the jejunal loops trapped (green long curve arrow) at the level of Landzert fossa, that was laterally to the fourth part of the duodenum (short green curve arrow).

Fig 3

This image describes the closed U loops appearance of the proximal jejunal bowels.