LETTERS TO THE EDITOR

 

Right-sided paraduodenal hernia: Rare cause of recurrent abdominal pain

Hernia paraduodenal derecha: una causa poco frecuente de dolor abdominal recurrente

 

 

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Key words: Paraduodenal hernia. Internal hernia. Intestinal obstruction.

Palabras clave: Hernia paraduodenal. Hernia internal. Obstrucción intestinal.

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Dear Editor,

Right-sided paraduodenal hernia (PH) is a rare congenital malformation that arises due to a defect in the rotation of the middle intestine during embryogenesis. Though it is usually an incidental finding on autopsy or during laparotomy, it can be responsible for episodes of recurring abdominal pain or even acute abdomen (1,2). A search of the literature only revealed three cases of right-sided PH diagnosed by computed tomography (CT) (3-5).

 

Case report

We present the case of a 52-year-old male, no prior history of abdominal surgery, with a several-month history of self-limiting episodes of colicky-type periumbilical abdominal pain associated with nausea. The patient came in due to a new episode of abdominal pain with rebound tenderness to deep palpation. Ultrasound and laboratory studies were unremarkable. Contrast CT of the abdomen revealed: "Displacement and bundling of the first loops of the jejunum towards the right flank with poster-inferior displacement of the colon suggestive of right-sided PH; no signs of intestinal obstruction or vascular compromise" (Fig. 1). Intestinal transit: "bundling of the loops of the jejunum in the right flank, no signs of obstruction." Given the recurrent nature of the case, the patient underwent a scheduled exploratory laparotomy that revealed a hernial sac with small intestine loops in its interior located on the right side, lateral and inferior to the descending portion of the duodenum. Surgery consisted of reduction of the intestinal loops in the hernial sac and subsequent repair of the defect. Four months later, the patient remained asymptomatic.

Discussion

Right-sided PH is the primary variant of internal hernias. These only make up 1-2 % of all abdominal hernias. It is a very uncommon entity that involves herniation of the all or part of the small intestine through a normal or anomalous foramen in the peritoneal cavity (3,6). There are two types: left-sided, which is more common (75 %), and right sided, which is very uncommon. This involves Waldeyer's fossa (a defect in the first part of the mesentery of the jejunum, located behind the superior mesenteric artery (SMA) and inferior to the 3^rd portion of the duodenum), the existence of which is normal in 1 % of the population (3).

PH can go unnoticed and is often found inadvertently. As in our case, it is usually diagnosed between the 4^th and 5^th decades of life in patients with a prior history of chronic abdominal pain and/or periodic abdominal distention caused by a partial intestinal obstruction that is occasionally attributed to a biliary condition, gastritis or signs and symptoms of gastroesophageal reflux (7,8). The intermittent character of the symptoms makes it difficult to diagnose. Although a barium study may suggest the existence of a right-sided PH by demonstrating an anomalous conglomeration of jejunal loops in the right quadrant, often displacing the adjacent organs such as the colon and SMA, CT is the most reliable procedure for preoperative diagnosis (9,10). There is an associated risk of strangulation and intestinal infarction for more than 50 % over the course of a lifetime, making it necessary to investigate radiological signs of hypoperfusion and intestinal ischemia (6). The high rate of mortality associated with these complications make early identification indispensable and justifies the role of abdominal CT in the early preoperative diagnosis of PH. Given the associated risk of strangulation, surgical treatment is recommended. Surgery can be performed in cases that lack intestinal necrosis or severe dilation.

 

Alicia Martín-Lagos-Maldonado, Elena Ruiz-Escolano,
María del Pilar Martínez-Tirado and Javier Salmerón-Escobar
Unit of Digestive Diseases. Hospital Universitario San Cecilio. Granada, Spain

 

References

1. Lin CT, Hsu KF, Hong ZJ, Yu JC, Hsieh CB, Chan DC, et al. A paraduodenal hernia (Treitz's hernia) causing acute bowel obstruction. Rev Esp Enferm Dig 2010;102:220-1.         [ Links ]

2. Fernández-Rey CL, Martínez-Álvarez C, Concejo-Cutoli P. Acute abdomen secondary to left paraduodenal hernia: diagnostic by multislice computer tomography. Rev Esp Enferm Dig 2011;103:38-9.         [ Links ]

3. Nuño CM, Arróniz J, Hernández C, Reyes F, Nava R, Guerrero F, et al. Right Paraduodenal Hernia in an Adult Patient: Diagnostic Approach and Surgical Management. Case Rep Gastroenterol 2011;5:479-86.         [ Links ]

4. Hernandorena M, Bértolo D, Dosda R, Torondel S. Hernias internas paraduodenales: hallazgos en la tomografía computarizada. Radiología 2009;51:444-6.         [ Links ]

5. Chih L, Liang L. Right-side paraduodenal hernia: unexplained recurrent abdominal pain. Clinical Imaging 2012;36: 68-71.         [ Links ]

6. Downes R, Cawich S. A case of a paraduodenal hernia. Int J Surg Case Rep 2010;1:19-21.         [ Links ]

7. Fan HP, Yang AD, Chang YJ, Juan CW, Wu HP. Clinical spectrum of internal hernia: a surgical emergency. Surg Today 2008;38:899-904.         [ Links ]

8. Chia L, Tung C, Pen L, Hong H, Kao L. Emergency management of an uncommon abdominal pain. Gut 2010:59:925.         [ Links ]

9. Martin L, Merkle E, Thompson W. Review of Internal Hernias: Radiographic and Clinical Findings. AJR 2006; 186:703-17.         [ Links ]

10. Lin CH, Ho YJ, Lin WC. Preoperative diagnosis of right paraduodenal hernia by multidetector computed tomography. J Formos Med Assoc 2008;107:500-4.         [ Links ]