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We present an unusual case of chronic obstruction due to internal herniation and the first documented case due to congenital agenesis of the gastrocolic and gastrohepatic ligaments in the context of malrotation.

Case report

A 61-year-old female presents with abdominal pain and intractable vomiting for one day’s duration on a background of several admissions over the past five years with repeated vomiting attributed to gastroenteritis. This was believed to be a paraduodenal hernia after discussion at our radiology meeting. On further questioning, she had previously had episodes similar to this and recurrent episodes of bloating and vague colicky abdominal pain for more than five years’ duration, including several presentations to the emergency department with intractable vomiting. Her symptoms settled rapidly after decompression and she was discharged home for semi-elective surgery the following week.

Figure 1: Diagram of the case: sagittal representation of normal anatomy vs omental agenesis and herniation.

c

Loops of the centrally located jejunum were herniating under the stomach via the congenital absence of the gastrocolic ligament and out onto the anterior aspect of the stomach via the congenital defect in the lesser omentum (see Figure 2). The herniated bowel was reduced and the defects closed with 2-0 PDS sutures to prevent recurrence, the small bowel mesentery was widened in a fashion similar to a Ladd’s procedure and an appendicectomy was performed to avoid diagnostic confusion in the future.

Figure 2: Loop of small bowel herniating behind the stomach and lacking any normal gastrocolic attachments of the omentum.

c

The bowel was noted to be partially malrotated with the duodenum crossing the midline (see Figure 3), with the sigmoid colon on the right side, the appendix in the left upper quadrant on an extremely mobile cecum and the small bowel sitting centrally on a narrow mesentery.

Figure 3: Intraoperative photo showing malrotation (with the appendix in the right upper quadrant).  

c

Discussion

Congenital obstruction attributable to malrotation is not as rare as previously thought and can present in any time from infancy to adulthood.1 As with this case, the presentation in adults is often indolent with a long lead time between first symptoms to diagnosis.1 Congenital malrotation due to defects in the normal omental attachments is very rare with only a dozen cases stretching back over the past 50 years.2–10 This is the first published case to occur due to malrotation and congenital absence of the gastrocolic and gastrohepatic ligaments. A high index of suspicion is required for diagnosing obstruction secondary to malrotation, and patients often wait many years to final diagnosis. Additional imaging with x-ray or CT imaging should be considered before attributing recurrent gastrointestinal symptoms to more benign conditions such as gastroenteritis.

Summary

Abstract

Aim

Method

Results

Conclusion

Author Information

- Paul VB Fagan, SET Trainee, Royal Australasian College of Surgeons; Registrar, Department of General Surgery, Taranaki Base Hospital, New Plymouth; Sam Dickson, Registrar, Department of General Surgery, Taranaki Base Hospital, New Plymouth; Nigel Hend

Acknowledgements

Correspondence

PVB Fagan, 13 Winscombe St, Belmont, Auckland 0622.

Correspondence Email

pvbfagan@gmail.com

Competing Interests

Nil.

  1. Nehra D, Goldstein AM. Intestinal malrotation: varied clinical presentation from infancy through adulthood. Surgery. 2011 Mar; 149(3):386–93.
  2. Stewart JOR. Lesser sac hernia. BJS. 2018 Nov 18; 50(221):321–6.
  3. Okayasu K, Tamamoto F, Nakanishi A, Takanashi T, et al. A case of incarcerated lesser sac hernia protruding simultaneously through both the gastrocolic and gastrohepatic omenta. Radiat Med. 2002; 20(2):105–7.
  4. Rathnakar SK, Muniyappa S, Vishnu VH, Kagali N. Congenital Defect in Lesser Omentum Leading to Internal Hernia in Adult : A Rare Case Report. J Clin Diagn Res. 2016; 10(8):9–10.
  5. Yasuda S, Inatsugi N, Sakurai T, Nakamura H, et al. A case of intestinal obstruction due to a hernia traversing the lesser sac. Jpn J Surg. 1989; 19(1):70–3.
  6. Chattopadhyay TK, Sarathy V V, Iyer KS. Internal herniation through gastrocolic and gastrohepatic omenta. Jpn J Surg. 1982; 12(6):453–5.
  7. Inoue Y, Nakamura H, Mizumoto S, Akashi H. Lesser sac hernia through the gastrocolic ligament : CT diagnosis. Abdom Imaging. 1996; (21):145–6.
  8. See JY, Ong AWH, Iau PTC, Chan STF. Double omental hernia--case report on a very rare cause of intestinal obstruction. Ann Acad Med Singapore. 2002 Nov; 31(6):799–801.
  9. Min J-S, Lee J-H, Jin S-H, Bang H-Y et al. Difficult diagnosis of a double omental hernia that led to extensive small bowel infarction. Hernia. 2010; 14(5):523–5.
  10. Li A, Hu R, Zhou D, Li S, et al. Internal herniation through lesser omentum hiatus and gastrocolic ligament with malrotation: a case report. J Med Case Rep. 2017; 1–4.

For the PDF of this article,
contact nzmj@nzma.org.nz

View Article PDF

We present an unusual case of chronic obstruction due to internal herniation and the first documented case due to congenital agenesis of the gastrocolic and gastrohepatic ligaments in the context of malrotation.

Case report

A 61-year-old female presents with abdominal pain and intractable vomiting for one day’s duration on a background of several admissions over the past five years with repeated vomiting attributed to gastroenteritis. This was believed to be a paraduodenal hernia after discussion at our radiology meeting. On further questioning, she had previously had episodes similar to this and recurrent episodes of bloating and vague colicky abdominal pain for more than five years’ duration, including several presentations to the emergency department with intractable vomiting. Her symptoms settled rapidly after decompression and she was discharged home for semi-elective surgery the following week.

Figure 1: Diagram of the case: sagittal representation of normal anatomy vs omental agenesis and herniation.

c

Loops of the centrally located jejunum were herniating under the stomach via the congenital absence of the gastrocolic ligament and out onto the anterior aspect of the stomach via the congenital defect in the lesser omentum (see Figure 2). The herniated bowel was reduced and the defects closed with 2-0 PDS sutures to prevent recurrence, the small bowel mesentery was widened in a fashion similar to a Ladd’s procedure and an appendicectomy was performed to avoid diagnostic confusion in the future.

Figure 2: Loop of small bowel herniating behind the stomach and lacking any normal gastrocolic attachments of the omentum.

c

The bowel was noted to be partially malrotated with the duodenum crossing the midline (see Figure 3), with the sigmoid colon on the right side, the appendix in the left upper quadrant on an extremely mobile cecum and the small bowel sitting centrally on a narrow mesentery.

Figure 3: Intraoperative photo showing malrotation (with the appendix in the right upper quadrant).  

c

Discussion

Congenital obstruction attributable to malrotation is not as rare as previously thought and can present in any time from infancy to adulthood.1 As with this case, the presentation in adults is often indolent with a long lead time between first symptoms to diagnosis.1 Congenital malrotation due to defects in the normal omental attachments is very rare with only a dozen cases stretching back over the past 50 years.2–10 This is the first published case to occur due to malrotation and congenital absence of the gastrocolic and gastrohepatic ligaments. A high index of suspicion is required for diagnosing obstruction secondary to malrotation, and patients often wait many years to final diagnosis. Additional imaging with x-ray or CT imaging should be considered before attributing recurrent gastrointestinal symptoms to more benign conditions such as gastroenteritis.

Summary

Abstract

Aim

Method

Results

Conclusion

Author Information

- Paul VB Fagan, SET Trainee, Royal Australasian College of Surgeons; Registrar, Department of General Surgery, Taranaki Base Hospital, New Plymouth; Sam Dickson, Registrar, Department of General Surgery, Taranaki Base Hospital, New Plymouth; Nigel Hend

Acknowledgements

Correspondence

PVB Fagan, 13 Winscombe St, Belmont, Auckland 0622.

Correspondence Email

pvbfagan@gmail.com

Competing Interests

Nil.

  1. Nehra D, Goldstein AM. Intestinal malrotation: varied clinical presentation from infancy through adulthood. Surgery. 2011 Mar; 149(3):386–93.
  2. Stewart JOR. Lesser sac hernia. BJS. 2018 Nov 18; 50(221):321–6.
  3. Okayasu K, Tamamoto F, Nakanishi A, Takanashi T, et al. A case of incarcerated lesser sac hernia protruding simultaneously through both the gastrocolic and gastrohepatic omenta. Radiat Med. 2002; 20(2):105–7.
  4. Rathnakar SK, Muniyappa S, Vishnu VH, Kagali N. Congenital Defect in Lesser Omentum Leading to Internal Hernia in Adult : A Rare Case Report. J Clin Diagn Res. 2016; 10(8):9–10.
  5. Yasuda S, Inatsugi N, Sakurai T, Nakamura H, et al. A case of intestinal obstruction due to a hernia traversing the lesser sac. Jpn J Surg. 1989; 19(1):70–3.
  6. Chattopadhyay TK, Sarathy V V, Iyer KS. Internal herniation through gastrocolic and gastrohepatic omenta. Jpn J Surg. 1982; 12(6):453–5.
  7. Inoue Y, Nakamura H, Mizumoto S, Akashi H. Lesser sac hernia through the gastrocolic ligament : CT diagnosis. Abdom Imaging. 1996; (21):145–6.
  8. See JY, Ong AWH, Iau PTC, Chan STF. Double omental hernia--case report on a very rare cause of intestinal obstruction. Ann Acad Med Singapore. 2002 Nov; 31(6):799–801.
  9. Min J-S, Lee J-H, Jin S-H, Bang H-Y et al. Difficult diagnosis of a double omental hernia that led to extensive small bowel infarction. Hernia. 2010; 14(5):523–5.
  10. Li A, Hu R, Zhou D, Li S, et al. Internal herniation through lesser omentum hiatus and gastrocolic ligament with malrotation: a case report. J Med Case Rep. 2017; 1–4.

For the PDF of this article,
contact nzmj@nzma.org.nz

View Article PDF

We present an unusual case of chronic obstruction due to internal herniation and the first documented case due to congenital agenesis of the gastrocolic and gastrohepatic ligaments in the context of malrotation.

Case report

A 61-year-old female presents with abdominal pain and intractable vomiting for one day’s duration on a background of several admissions over the past five years with repeated vomiting attributed to gastroenteritis. This was believed to be a paraduodenal hernia after discussion at our radiology meeting. On further questioning, she had previously had episodes similar to this and recurrent episodes of bloating and vague colicky abdominal pain for more than five years’ duration, including several presentations to the emergency department with intractable vomiting. Her symptoms settled rapidly after decompression and she was discharged home for semi-elective surgery the following week.

Figure 1: Diagram of the case: sagittal representation of normal anatomy vs omental agenesis and herniation.

c

Loops of the centrally located jejunum were herniating under the stomach via the congenital absence of the gastrocolic ligament and out onto the anterior aspect of the stomach via the congenital defect in the lesser omentum (see Figure 2). The herniated bowel was reduced and the defects closed with 2-0 PDS sutures to prevent recurrence, the small bowel mesentery was widened in a fashion similar to a Ladd’s procedure and an appendicectomy was performed to avoid diagnostic confusion in the future.

Figure 2: Loop of small bowel herniating behind the stomach and lacking any normal gastrocolic attachments of the omentum.

c

The bowel was noted to be partially malrotated with the duodenum crossing the midline (see Figure 3), with the sigmoid colon on the right side, the appendix in the left upper quadrant on an extremely mobile cecum and the small bowel sitting centrally on a narrow mesentery.

Figure 3: Intraoperative photo showing malrotation (with the appendix in the right upper quadrant).  

c

Discussion

Congenital obstruction attributable to malrotation is not as rare as previously thought and can present in any time from infancy to adulthood.1 As with this case, the presentation in adults is often indolent with a long lead time between first symptoms to diagnosis.1 Congenital malrotation due to defects in the normal omental attachments is very rare with only a dozen cases stretching back over the past 50 years.2–10 This is the first published case to occur due to malrotation and congenital absence of the gastrocolic and gastrohepatic ligaments. A high index of suspicion is required for diagnosing obstruction secondary to malrotation, and patients often wait many years to final diagnosis. Additional imaging with x-ray or CT imaging should be considered before attributing recurrent gastrointestinal symptoms to more benign conditions such as gastroenteritis.

Summary

Abstract

Aim

Method

Results

Conclusion

Author Information

- Paul VB Fagan, SET Trainee, Royal Australasian College of Surgeons; Registrar, Department of General Surgery, Taranaki Base Hospital, New Plymouth; Sam Dickson, Registrar, Department of General Surgery, Taranaki Base Hospital, New Plymouth; Nigel Hend

Acknowledgements

Correspondence

PVB Fagan, 13 Winscombe St, Belmont, Auckland 0622.

Correspondence Email

pvbfagan@gmail.com

Competing Interests

Nil.

  1. Nehra D, Goldstein AM. Intestinal malrotation: varied clinical presentation from infancy through adulthood. Surgery. 2011 Mar; 149(3):386–93.
  2. Stewart JOR. Lesser sac hernia. BJS. 2018 Nov 18; 50(221):321–6.
  3. Okayasu K, Tamamoto F, Nakanishi A, Takanashi T, et al. A case of incarcerated lesser sac hernia protruding simultaneously through both the gastrocolic and gastrohepatic omenta. Radiat Med. 2002; 20(2):105–7.
  4. Rathnakar SK, Muniyappa S, Vishnu VH, Kagali N. Congenital Defect in Lesser Omentum Leading to Internal Hernia in Adult : A Rare Case Report. J Clin Diagn Res. 2016; 10(8):9–10.
  5. Yasuda S, Inatsugi N, Sakurai T, Nakamura H, et al. A case of intestinal obstruction due to a hernia traversing the lesser sac. Jpn J Surg. 1989; 19(1):70–3.
  6. Chattopadhyay TK, Sarathy V V, Iyer KS. Internal herniation through gastrocolic and gastrohepatic omenta. Jpn J Surg. 1982; 12(6):453–5.
  7. Inoue Y, Nakamura H, Mizumoto S, Akashi H. Lesser sac hernia through the gastrocolic ligament : CT diagnosis. Abdom Imaging. 1996; (21):145–6.
  8. See JY, Ong AWH, Iau PTC, Chan STF. Double omental hernia--case report on a very rare cause of intestinal obstruction. Ann Acad Med Singapore. 2002 Nov; 31(6):799–801.
  9. Min J-S, Lee J-H, Jin S-H, Bang H-Y et al. Difficult diagnosis of a double omental hernia that led to extensive small bowel infarction. Hernia. 2010; 14(5):523–5.
  10. Li A, Hu R, Zhou D, Li S, et al. Internal herniation through lesser omentum hiatus and gastrocolic ligament with malrotation: a case report. J Med Case Rep. 2017; 1–4.

Contact diana@nzma.org.nz
for the PDF of this article

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