Congenital internal hernia as a cause of small bowel obstruction: CT findings in 11 adult patients

The aim of this study is to report the CT findings in patients proved to have congenital internal hernia (CIH) as a cause of small bowel obstruction (SBO). The CT scans of 11 patients (9 men and 2 women, with ages ranging from 20 years to 95 years (mean 60.7 years), presenting with clinical symptoms and signs of SBO without previous abdominal surgery or trauma, were retrospectively reviewed. In all patients features of SBO were seen. In addition, in nine of them a saclike mass, containing dilated small bowel loops with mesenteric vessels converging toward its orifice was demonstrated and a pre-operative diagnosis of an incarcerated internal hernia was suggested. In the other two, a closed loop obstruction was seen without an identifiable cause. Mural thickening of the entrapped loops within the hernial sac was seen in five patients, with hypoperfusion in four of them, blurring of the mesenteric vessels with localized mesenteric fluid was demonstrated in seven and free peritoneal fluid in 10. All patients were operated on following the CT and an incarcerated CIH was confirmed. Gangrenous bowel was present at exploration in seven cases. One patient died. In conclusion, in patients with intact abdomen and SBO, CT may be the first imaging modality to discover a clinically unsuspected CIH, which requires prompt surgical intervention. Radiologists should be aware of the CT features suggestive of a SBO caused by CIH, i.e. a saclike mass of dilated small bowel loops, as a correct diagnosis will influence patient management and prognosis.     

Perineal hernia

Abdominal wall hernias are a common abdominal pathology with higher prevalence in our population. It is usually asymptomatic but complications such as strangulation, incarceration or bowel obstruction need early detection and emergency surgery. The purpose of this article is to describe the infrequent type of hernia, illustrate the imaging findings and review the differential diagnosis. A 76-year-old woman was admitted in the emergency room with abdominal pain, vomits and diarrhoea. At her admission, a colonoscopy was attempted to perform but it was not possible to go beyond the stenosis. A barium enema and a multi-detector computed tomography (MDCT) were performed revealing a large mass in the left ischiorectal fossa, containing herniated loops of sigmoid colon adjacent to rectum. Abdominal wall hernias occur at areas of congenital or acquired weakness in the abdominal wall and are considered external hernias. MDCT is essential to identify wall hernias, make an accurate diagnosis and help for its clinical assessment. Knowing the radiological features of various types of abdominal hernias on MDCT and barium-enhanced radiographs allows confident diagnosis of these pathologies.     

腹股沟及其周围疝所致肠梗阻CT诊断

目的 探讨CT对腹股沟及其周围疝所致肠梗阻的诊断价值.资料与方法 回顾性分析17例经手术证实的腹股沟及其周围疝所致肠梗阻的CT表现,CT检查包括全腹部平扫、动脉期及门脉期增强.结果 17例患者均有不同程度的肠梗阻表现,腹股沟斜疝9例,CT表现为疝囊内肠管从腹壁下动脉外侧、腹股沟韧带前上方走行,行经腹股沟管内;直疝1例,CT表现为扩张的小肠肠管从腹壁下动脉内侧的直疝三角区(Hesselback三角)直接由后向前突出,疝囊不进入阴囊;股疝3例,CT表现为股疝疝囊位于股三角区、耻骨结节水平线以后、腹股沟韧带后下方;闭孔疝4例,CT表现为闭孔外肌与耻骨肌之间的肠管影和腹部肠管相连.结论 CT检查能明确诊断腹股沟及其周围疝所致肠梗阻.     

Abdominal wall hernias: imaging with spiral CT

Computed tomography is an accurate method of identifying the various types of abdominal wall hernias, especially if they are clinically occult, and of distinguishing them from other diseases such as hematomas, abscesses and neoplasia. In this study we examined the CT images of 94 patients affected by abdominal wall hernias observed over a period of 6 years. Computed tomography clearly demonstrates the anatomical site of the hernial sac, the content and any occlusive bowel complications due to incarceration or strangulation. Clinical diagnosis of external hernias is particularly difficult in obese patients or in those with laparotic scars. In these cases abdominal imaging is essential for a correct preoperative diagnosis and to determine the most effective treatment. Received: 20 May 1999; Revised: 10 August 1999; Accepted: 13 August 1999     

A spontaneous strangulated transomental hernia: Prospective and retrospec-tive multi-detector computed tomography findings Camera L,De Gennaro A,Longobardi M,Masone S,Calabrese E,Del Vecchio W,Persico G,Salvatore M简

Transomental hernias are among the rarest type of all internal hernias which overall account for less than 6% of small bowel obstructions. Most transomental hernias occurring in adults are either iatrogenic or post-traumatic. More rarely, a spontaneous herniation of small bowel loops may result from senile atrophy of the omentum. We report a case of an 86-year-old male who presented with signs and symptoms of small bowel obstruction but had no past surgical or traumatic abdominal history. At contrast-enhanced multi-detector row computed tomography (CT), a cluster of fluid-filled dilated small bowel loops could be appreciated in the left flank, with associated signs of bowel wall ischemia. Swirling of the mesenteric vessels could also be appreciated and CT findings were prospectively considered consistent with a strangulated small bowel volvulus. At laparotomy, no derotation had to be performed but up to 100 cm of gangrenous small bowel loops had to be resected because of a transomental hernia through a small defect in the left part of the greater omentum. Retrospective reading of CT images was performed and findings suggestive of transomental herniation could then be appreciated.     

Adult celiac disease: US signs

PURPOSE: To examine whether distinct ultrasonographic (US) signs exist in patients with adult celiac disease. MATERIALS AND METHODS: In a partly retrospective study, abdominal sonograms were obtained in 11 patients with adult celiac disease. Fifty matched control subjects also were examined. After the patients had fasted overnight, they were examined with 2-4-MHz abdominal and high-frequency 5-10-MHz linear-array US transducers. RESULTS: The authors found several US pathologic signs in patients with untreated disease, including abnormal fluid-filled small intestine in all 11 patients, flaccid and moderately dilated small-bowel loops (2.5-3.5 cm) in eight, slight diffuse thickening of the small-bowel wall (3-5 mm) in seven, increased peristalsis of the small intestine in eight, enlarged mesenteric lymph nodes (anteroposterior diameter 5-10 mm) in nine, dilated caliber of the superior mesenteric artery or portal vein in seven, free fluid in the abdominal cavity in five, and increased echogenicity of the liver in six. None of these signs was present in the control group. CONCLUSION: There are several US signs associated with adult celiac disease. None of the signs identified is specific, but a combination of signs is characteristic and indicates suspicion of this disease in a high percentage of cases. US could help to avoid diagnostic delay, especially in patients who have atypical clinical presentations.     

CT diagnosis of delayed presentation of congenital diaphragmatic hernia simulating massive pleuropneumonia

A case of an 11-month-old infant with a delayed presentation of congenital diaphragmatic hernia is reported. Incarceration of the herniated colon caused a misleading appearance on the chest X-ray which was interpreted as massive pleuropneumonia. Computed tomography, performed because of continuing deterioration in the clinical condition, showed fluid-filled bowel loops in the chest and dilated bowel loops with air–fluid levels in the abdomen, suggesting the correct diagnosis. Received: 17 June 1998; Revision received: 8 September 1998; Accepted: 17 November 1998     

MDCT imaging in Spigelian hernia,clinical, and surgical implications

ObjectiveSpigelian hernia is an uncommon congenital or acquired defect in the transversus abdominis aponeurosis with non-specific symptoms posing a diagnostic challenge. There is a paucity of radiology literature on imaging findings of Spigelian hernia. The objective of this study is to explore the role of MDCT in evaluating Spigelian hernia along with clinical and surgical implications.Materials and methodsIn this IRB approved, HIPAA compliant retrospective observational analysis MDCT imaging findings of 43 Spigelian hernias were evaluated by two fellowship-trained radiologists. Imaging features evaluated were: presence of Spigelian hernia, laterality, relation to “hernia belt” (between 0 and 6 cm cranial to an imaginary axial line between both anterior superior iliac spines), the hernia neck and sac sizes, hernia content, and other coexistent hernias (umbilical, incisional, inguinal). Patient's demographics (age, gender, BMI, conditions with increased intra-abdominal pressure) were also recorded for any correlation.Results60% (26/43) of Spigelian hernias were located below the hernia belt while 33% (14/43) within the hernia belt and 7% (3/43) above the hernia belt. The most common subtype of Spigelian hernia encountered was interparietal (84%). The mean hernia neck diameter was 3.4 cm, mean hernia sac volume was 329 cc. Hernia content included: fat (43/43) bowel (23/43), fluid (3/43). 3 patients had no clinical history provided, the remaining 37 patients' clinical presentation was asymptomatic in 73% (27/37), acute abdominal pain in 5% (2/37) and chronic abdominal pain in 22% (8/37). None of the hernia were incarcerated and none of the patients underwent emergent surgery. No significant correlation was noted between Spigelian hernia and causes of increased intra-abdominal pressure. 90% of our patients had other abdominal hernias. 30.9 was the mean BMI (20.8–69.1).ConclusionMost of the Spigelian hernia occurred below the traditionally described hernia belt and the majority are of interparietal subtype that can be best diagnosed with MDCT in contrast to physical examination.     

Closed-loop obstruction of the small bowel: CT and sonographic appearance

Two patients with closed loop obstruction diagnosed by CT and sonography are reported. Abdominal radiograph was nonspecific. The characteristic CT and sonographic features included (a) isolated conglomerate of dilated, fluid-filled bowel loops; (b) fixation of these "U" shaped distended loops; (c) thickened bowel wall; and (d) extraluminal fluid.     

Radiologist performance in the diagnosis of internal hernia by using specific CT findings with emphasis on transmesenteric hernia.

PURPOSE: To evaluate the performance of radiologists in the diagnosis of internal hernia with specific computed tomographic (CT) findings. MATERIALS AND METHODS: Abdominal CT scans obtained in 42 patients were retrospectively reviewed by three radiologists. The case group consisted of 18 patients with internal hernias (two paraduodenal, 16 transmesenteric); the comparison group was 24 patients with no internal hernia. Images were reviewed in a random and blinded fashion. Individual and group performance was evaluated with receiver operating characteristic (ROC) analysis, and interobserver agreement was measured with Cronbach coefficient alpha. Individual CT signs relevant as predictors of transmesenteric hernia were identified with logistic regression analysis and ranked by their odds ratio and P values. RESULTS: Both paraduodenal hernias were diagnosed by all readers on the basis of CT signs, including a retrogastric saclike mass of small-bowel loops. Diagnosis of transmesenteric hernia was more difficult and variable, with an average accuracy of area under the ROC curve (A(z)) of 77%, sensitivity of 63%, and specificity of 76%. CT signs of transmesenteric hernia were recognized consistently (Cronbach coefficient alpha >or= 0.80) and included a cluster of dilated small-bowel segments and stretching and displacement of mesenteric vessels. Coexisting volvulus and ischemia were diagnosed with low sensitivity (46% and 43%, respectively) but high specificity (96% and 98%, respectively). CONCLUSION: Diagnosis of internal hernia with CT remains difficult. Special attention should be given to the clustering of bowel loops, the mesenteric vessels, and signs of small-bowel obstruction.     

Internal hernia: clinical and imaging findings in 17 patients with emphasis on CT criteria

PURPOSE: To review the clinical and radiologic features of internal hernia and to derive useful radiographic and CT criteria to assist in diagnosis. MATERIALS AND METHODS: Retrospective review of medical records revealed 17 patients with surgically proved internal hernia (three paraduodenal, 14 transmesenteric) who had 15 computed tomographic (CT) scans and three small-bowel follow-through (SBFT) images. RESULTS: CT signs common to all types of internal hernia included evidence of small-bowel obstruction; clustering of small bowel; stretched, displaced, crowded, and engorged mesenteric vessels; and displacement of other bowel segments, especially the transverse colon and fourth portion of the duodenum. Left-sided paraduodenal hernias demonstrated a sac-like mass of small-bowel loops interposed between the stomach and pancreatic tail and a posterior mass effect on the stomach. All three paraduodenal hernias were diagnosed confidently at retrospective review of CT and SBFT findings. Transmesenteric hernias demonstrated clustered small-bowel loops adjacent to the abdominal wall without overlying omental fat and central displacement of colon and were frequently complicated by small-bowel volvulus (five of 14) and bowel ischemia (six of 14). CT demonstrated signs of volvulus in four of six patients with ischemia. CT findings considered definitive or suggestive of internal hernia were demonstrated in 15 patients. CONCLUSION: Internal hernia is an important and underdiagnosed condition. Transmesenteric hernia is most common in our experience and is usually related to prior abdominal surgery, especially with creation of a Roux-en-Y anastomosis. CT may allow confident diagnosis in most patients.     

Small bowel obstruction due to incarcerated sciatic hernia: ultrasound diagnosis

A 71-year-old woman presented with vomiting, abdominal pain and vague right gluteal discomfort. Abdominal ultrasound showed ascites and dilated small bowel loops with peristaltic movement, while transgluteal ultrasound revealed entrapped ascites beneath gluteal muscles and an oedematous, immobile bowel loop trapped between the sacrum and iliac bone with barely visible colour Doppler flow suggestive of an incarcerated sciatic hernia. CT demonstrated similar findings and subsequent surgery confirmed the diagnosis. To our knowledge, this is the first report of a pre-operative diagnosis of incarcerated sciatic hernia on ultrasound.     

MSCT多平面重组诊断单纯性横膈网膜疝

目的探讨MSCT多平面重组（multipleplanarreconstruction,MPR）诊断单纯性横膈网膜疝（simpleomentaldiaphragmatichernia,SODH）的价值。方法31例SODH均行MSCT容积扫描并作亚毫米重组,3名不知手术结果的高年资医师回顾性分析横断位和MPR图像,以发现膈肌中断缺损、膈上脂肪疝囊、“狭颈征”及“阳性血管征”作为诊断SODH依据;横断位及MPR征象显示及诊断差异采用x。检验。结果31例SODH中Bochdalek疝15例、Morgagni疝4例、医源性膈疝3例、食管裂孔疝6例及腔静脉裂孔疝3例,膈肌中断缺损、膈上疝囊、“狭颈征”及“阳性血管征”横轴位和MPR依次分别显示：6例和22例6．67,P〈O．01）、31例和31例、6例和28例（x2=31．52,Pd0．01）及3例和11例（x2=5．90,Pd0．05）。横轴位诊断12例,MPR全部明确诊断（x2=27．40,P〈0．01）。结论MSCTMPR清晰显示SODH多种特征性征象,对诊断具有决定意义。     

Gastrointestinal sonographic findings in Henoch-Schönlein purpura

The objective of this study was to document the spectrum of sonographic findings in the gastrointestinal tract of children with abdominal pain due to Henoch-Schönlein purpura. The abdominal ultrasound images of 13 consecutive patients with Henoch-Schönlein purpura were retrospectively analyzed, with special attention to the following findings: thickened bowel wall; dilated, obstructed intestinal loops; free peritoneal fluid; intussusception; and miscellaneous findings.All 13 patients demonstrated one or more segments of thickened intestine, usually in the small intestine. Circumferential, echogenic thickening of the mucosa and submucosa was the most common finding (10 of 13 patients). In one patient, mucosal thickening was asymetric, and two patients demonstrated findings which at first suggested intussusception but later were found to represent intramural hematomas. Free peritoneal fluid was seen in seven patients (53.8%).Ultrasound is sensitive, but not specific, in detecting gastrointestinal manifestations of Henoch-Schönlein purpura. The most common finding is segmental, circumferential, echogenic thickening of the intestinal wall. Free peritoneal fluid also is a relatively common finding, and, in addition, intramural hematoma can be a problem because its configuration can be mistaken for intussusception, a well-known complication of this disease.     

Use of novel photon – counting detector CT for diagnosis of bowel infarction

A 75 year old male with a history of thoraco-abdominal surgery presented with acute onset epigastric pain. CT of the abdomen and pelvis with contrast performed on a novel photon-counting detector CT demonstrated dilated loops of small bowel herniating into the thoracic cavity through a defect in the left hemidiaphragm. On conventional CT reconstructions, the bowel wall demonstrated a thin rim of hyper-density which could have been interpreted as normal mucosal enhancement in viable bowel. However, spectral-imaging data including the iodine map revealed a complete lack of enhancement within the herniated loops of bowel compatible with infarction. With the added diagnostic information, the patient was taken rapidly to surgery for small bowel resection, with good outcome.     

Small bowell volvulus - combined radiological findings]

PURPOSE: We retrospectively evaluated the radiological findings observed at plain abdominal film, abdominal sonography and abdominal CT performed in 66 patients with surgically proven small bowel volvulus. MATERIAL AND METHODS: Sixty-six patients (35 women and 31 men, ranging in age 38-77 years) with surgically proven small bowel volvulus were submitted to plain film, sonography and CT of the abdomen. Abdominal plain film was performed in the upright position (postero-anterior view) in 46 cases, and in the supine position in 20 cases. On plain abdominal film we evaluated the following findings: bowel loops dilatation, air-fluid levels and site of obstruction. At abdominal US, performed with 3.5 e 7.5 MHz probes, we retrospectively searched for: bowel loop dilatation, bowel wall thickening, peristalsis alteration, extraluminal fluid. CT was performed with a helical unit (thickness 4 mm, reconstruction interval 4 mm, pitch 1.5), after intravenous contrast agent (120 ml) infusion (3 ml/s, 55 s acquisition delay from bolus starting) and using a power injector. The following CT findings were searched for: whirl sign, beak sign, extraluminal fluid, bowel loop dilatation, bowel wall thickening, bowel wall or mesenteric alterations. RESULTS: Plain abdominal film showed the following findings: air-fluid levels (92.4% of cases), bowel loops dilatation (71.2%), site of obstruction (42.4%). Abdominal sonography demonstrated bowel loop dilatation (48.5%), extraluminal fluid (48.5%), peristalsis alteration (27.3%), bowel wall thickening (27.3%). The most frequent CT findings were: bowel loop dilatation (95.5%), bowel wall thickening (78.8%), beak sign (69.7%), mesenteric alterations (66.7%), extraluminal fluid (54.5%), whirl sign (13.6%). CONCLUSIONS: Air-fluid levels and bowel loop dilatation were the most frequent radiological findings in our series. Plain abdominal film allowed us to identify signs of obstruction, whereas signs of bowel wall necrosis were accurately shown by abdominal CT.     

CT demonstration of traumatic ventral hernia and diaphragmatic rupture. A case report

Traumatic ventral hernias occur rarely. A case is presented where bowel has herniated through a traumatic defect of the anterior abdominal musculature, demonstrated by CT. This has not been previously reported in the literature. These loops of bowel showed mural thickening and high density indicating severe injury and were found at laparotomy to be ischaemic. The patient simultaneously suffered rupture of the right hemidiaphragm, also demonstrated by CT and also an uncommon injury.     

Bowel obstruction following liver transplantation: clinical and ct findings in 48 cases with emphasis on internal hernia

PURPOSE: To review the incidence, cause, and radiologic findings of bowel obstruction in patients who have undergone orthotopic liver transplantation (OLT). MATERIALS AND METHODS: Retrospective review of 4,001 cases of OLT revealed 48 cases of bowel obstruction in 44 patients. Seventeen computed tomographic (CT) scans and seven barium-enhanced radiographs were reviewed to determine level and cause. Surgical proof was available in 45 cases, while three had characteristic clinical and radiographic features. RESULTS: Adhesions caused the obstruction in 19 cases in 16 patients; three had bowel ischemia. Internal hernias caused obstruction in 18 patients; all obstructions were transmesenteric or retroanastomotic and occurred with choledochoenteric anastomosis. Seven patients had volvulus; four had bowel ischemia. CT signs of internal hernia included mesenteric vascular abnormalities and clusters of dilated small-bowel segments that displaced the colon away from the abdominal wall. Prospective diagnosis of internal hernia was made in only one case. Incisional or inguinal hernia caused obstruction in seven patients; CT was used just once. Four patients had neoplastic bowel obstruction, three due to posttransplantation lymphoproliferative disorder and one due to colon carcinoma. CONCLUSION: Liver transplantation was complicated by bowel obstruction in 48 (1.2%) of 4,001 cases. While adhesions and incisional hernias are common and well recognized, other causes are more challenging to diagnose. The CT findings reported here may allow more accurate diagnosis of internal hernia.     

闭孔疝CT诊断(附9例报告)

目的探讨CT诊断闭孔疝的价值和临床意义,提高对闭孔疝的认识。方法回顾分析9例经CT术前检查、并为手术证实的闭孔疝CT表现。结果右侧闭孔疝7例,左侧闭孔疝2例。CT表现主要有小肠梗阻,空回肠肠管扩张、积液;在闭孔外肌和耻骨肌之间可见疝囊;闭孔疝绞窄时,可见肠壁增厚、水肿,增强扫描强化减弱;腹腔可见积液。结论CT检查是闭孔疝的有效检测手段,对老年患者,特别是老年女性患者的不明原因肠梗阻,腹部CT检查将有助于临床确诊。     

CT findings of small bowel strangulation: the importance of contrast enhancement

The purpose of this study is to illustrate computed tomography (CT) findings suggestive of small bowel strangulation. We have performed the precontrast and postcontrast CT with single and multidetector CT scanners and evaluated the bowel wall changes and mesentery changes and correlated them with the operative findings. The direct CT findings suggestive of small bowel strangulation included high-density bowel wall on precontrast scans; lack of, or diminished contrast enhancement of the involved bowel wall; localized mesenteric fluid accumulation (mesenteric congestion); and localized pneumatosis. The indirect CT signs included C- or U-shaped loops with mesenteric vessels converging toward the obstruction site, ascites, target sign, two adjacent collapsed round loops, and whirl sign. We particularly emphasize the importance of contrast enhancement of bowel mucosa for early diagnosis to differentiate strangulation from a mechanical obstruction without bowel ischemia, and also the importance to differentiate proximal secondary gas-filled dilated small bowel loops from distal primary involved fluid-filled small bowel loops because these two types of small bowel loops are present in the single peritoneal cavity. As early recognition of small bowel strangulation may help improve the patient outcome because the involved bowel loops can be preserved without resection, it is essential to become familiar with the CT signs suggested small bowel obstruction strangulation.