Adhesive internal hernia: multidetector CT findings and clinical relevance

Small bowel obstruction and strangulation secondary to an adhesive internal hernia post ESWL for right ureteral calculi: a case report and review of literature

Background

Extracorporeal shock wave lithotripsy (ESWL) is a relatively safe and convenient mode of treatment for ureteral and renal stones, despite its relative safety; ESWL is not without its complications. We present a case of a patient we managed for small bowel obstruction and strangulation due to an adhesive internal hernia after ESWL was done because of right ureteral calculi.

Case presentation

We report a case of a 59-year-old patient who presented with severe abdominal pain a few hours after ESWL because of a right upper ureteric calculus. The abdominal pain increased in severity in time and became more generalized. The patient had one episode of gross hematochezia as she was being prepped for emergency laparotomy. Intra-op, she had a strangulated internal hernia because of an omental-mesenteric adhesion.

Conclusion

This case report hopes to highlight the potential of complications like acquired IH due to adhesions in patients with a history of ureteral calculi, and also the complications that may come about post-ESWL. Patients who present with signs of persistent abdominal pain post-ESWL should be vigilantly observed. If symptoms persist, increase in intensity or there is a general deterioration of the patients’ hemodynamic status, even in light of negative MDCT findings, prompt surgical intervention is crucial for definitive diagnosis as well as management.

Multidetector Computed Tomography Findings of Adhesive Internal Hernias

OBJECTIVE

To identify multidetector computed tomography (MDCT) findings of surgically confirmed adhesive internal hernias (IHs).

METHODS

Two gastrointestinal radiologists performed blinded, independent, and retrospective reviews of MDCT findings from a consecutive cohort of 35 adhesive IH and 41 adhesive small-bowel obstruction cases that had undergone surgery within 48 hours after MDCT. Univariate statistical analyses were performed to assess CT signs of adhesive IHs and CT findings of intestinal necrosis in patients presenting with adhesive IHs.

RESULTS

Dislocated cluster of the intestine (P = 0.005), 2 transitional zones (P = 0.002), and presence of fat in the center sign (P = 0.001) were key CT outcomes that were significantly associated with adhesive IHs. Additionally, intramural hemorrhage was found the MDCT feature indicative of intestinal necrosis (P = 0.028).

CONCLUSIONS

This study illustrates specific MDCT findings of IHs, and these observations may help guide early clinical management of the condition.

Adhesive and non-adhesive internal hernia: clinical relevance and multi-detector CT images

Internal hernia (IH)-related surgical acute abdomen is not well understood because of the rarity of cases and underdiagnosis. This study was performed to further understand the clinicopathological features and multi-detector computed tomography (MDCT) findings of IH in cases confirmed by surgery. In all, 51 patients with a definite diagnosis of IH confirmed during surgical exploration from Feb. 2012 to Feb. 2018 in our hospital were included in this research. Medical records, including MDCT images and intra-operative findings, were collected retrospectively. In all, 39 and 12 cases were categorized as adhesive IH (76.5%) and non-adhesive IH (23.5%), respectively. Among the patients with adhesive IH, 73% had a history of abdominal or pelvic surgery. Additionally, the mesentery was the most common component of adhesive bands (64.1%). Congenital peritoneal abnormalities and gastrointestinal reconstruction were the main causes of non-adhesive IH.As a specific sign, the fat notch sign was much more common in adhesive IH than in non-adhesive IH (P = 0.023). Bowel wall thickening (P = 0.041), abnormal bowel wall enhancement (P = 0.006) and twisted bowels with the vessel swirl sign (P = 0.004) were indicators of bowel necrosis. Among all of the cases of IH, 34 (66.7%) were complicated by bowel necrosis, and 1 patient died. In conclusion, non-adhesive IH has different clinicopathological features and MDCT findings from those of adhesive IH. MDCT is a useful tool with high sensitivity for confirming IH and may help to guide the early treatment of IH.