Internal hernia and volvulus of the small bowel following liver transplantation

Abstract

Internal herniation with volvulus of the small intestine is an uncommon, but potentially fatal, complication after liver transplantation. We present here four cases in which the herniation occurred around the Roux-en-Y loop used for the biliary reconstruction. One patient died due to intestinal and liver allograft necrosis; another lost almost the entire small intestine and has since undergone successful intestinal transplantation. Two patients survived following surgery that involved reduction of the hernia and closure of the mesenteric defect. Clinical diagnostic implications emphasize early diagnosis and appropriate operative intervention.

Fig. 1

a Film of abdomen taken in supine position. b Left lateral decubitus abdominal radiographs are nonspecific with diffuse, moderately dilated bowel loops and scattered air-fluid levels. c CT scan of the abdomen reveals moderate abdominal ascites. Note the dilated proximal duodenum (arrow) but the normal anatomic position of the superior mesenteric artery (a), to the left and posterior in relation to the superior mesenteric vein (V). d CT slice several centimeters inferior to c. Note the diffusely distributed, markedly dilated, fluid-filled small bowel loops with air-fluid levels and poor wall enhancement. There is a whorl appearance in the right posterior abdomen (arrows) consisting of twisted loops of bowel and mesentery around the superior mesenteric artery. This appearance is diagnostic of small bowel volvulus