Case Report 01012

Submitted by: Dongni Yang, M.D. Ph.D.

Faculty reviewer: Dr. Verghese George, M.D
Date accepted: 05 March 2014
Radiological Category: Principal Modality (1):
Principal Modality (2):
GI
none
CT
Case History
40 yo female presented with abdominal pain, nausea and vomiting for 2 days

PMH: DM, HTN

PSH: Gastric bypass 2 years ago

Med: None

PE: upper abdomen tender to palpation with involuntary guarding

Patient received CT abdomen and pelvis in the ER
Radiological Presentations
Cranial to caudal axial images
Radiological Presentations
Malrotation , volvulus and small bowel obstruction (SBO)
Hernia, including internal hernia and SBO
Small bowel tumors causing SBO
Primary: GIST, lymphoma, adenocarcinoma
Metastatic: melanoma , etc
Adhesion and SBO
Stricture and SBO
Intussesception
SMA syndrome
Bowel ischemia
Enteritis






Which one of the following is your choice for the appropriate diagnosis? After
your selection, go to next page.
Test Your Diagnosis
1. Prior gastric bypass surgery

2. Dilation of the gastric pouch and Roux limb

3. Collapsed distal small and large bowel

4. Twisting of mesenteric vessels and fat

5. Small bowel mesenteric edema


Findings:
Differentials:
Findings and Differentials
Internal hernia causing SBO
Adhesion causing SBO
Stricture causing SBO
Kinking causing SBO
Bezoars causing SBO
Intusscusception






Patient was taken to the OR

Operative findings:
Herniation through Petersens space and twisting of the small bowel
mesentary several times.

The Roux limb and the proximal small bowel were ischemic.

After reduction of the hernia and untwisting of the small bowel, all the
bowel loops appear viable.

The Petersens space was closed with sutures.




Discussion
Internal hernias:

Congenital
Foramen of Winslow
Paraduodenal (left and right)
Transmesenteric
Transomental
Pericecal
Intersigmoid
Supravesical and pelvic

Aquired (from surgery, trauma, inflammation and infection)
In this patient, there is aquired hernia from Roux-en-Y gastric bypass

Discussion


Roux-en-Y gastric bypass can be complicated by internal hernias through the
following defects:

defect in the transverse mesocolon through which the Roux limb passes
(if retrocolic in position);

mesenteric defect at the enteroenterostomy;

retro-Roux defect (Petersens defect or Petersens space), as bounded by
transverse mesocolon, retroperitoneum and the Roux limb mesentery.




Discussion
Discussion
Petersens
defect
Transverse
mesocolon defect
Mesenteric defect at the
enteroenterostomy
Common complications after Roux-en-Y gastric bypass:
Leak
Obstruction
Hemorrhage
Internal hernia
Stricture
Widened anastomosis

Upper GI studies and CT are commonly used to assess the complications.
Discussion
Diagnosis of internal hernia:
cluster of bowel loops at abnormal location
small bowel loop entering and exiting hernia
small bowel obstruction may or may not be seen
converging vessels or abnormal mesenteric vascular pedicle

(Internal hernia may occur in 20% of patient with normal CT.)

Internal hernia occurs more often after laparoscopic Roux-en-Y gastric bypass
compared to open surgery, ranging from 1.6- 5%. This is thought to be due to lack
of adhesion which allow more bowel mobility.

Usually all potential spaces are closed during surgery, however, weight loss may
allow the spaces to expand.

Discussion




Small bowel obstruction with ischemia due to a Petersens hernia in a patient with
previous gastric bypass surgery












Diagnosis
Takeyama et. al. CT of internal Hernias. Radiographics 2005; 25:997-1015

Carucci et. al. Internal Hernia following Roux-en-Y bypass surgery for morbid obesity:
evaluation of radiographic findings at small bowel examination Radiology 2009; 251
(3): 762-770

Sheirey et. al. Radiology of the Laparoscopic Roux-en-Y Gastric Bypass Procedure:
Conceptualization and Precise Interpretation of Results. Radiographics 2006; 26:1355-
1371

Faria et. al. Petersons space hernia: A rare but expanding diagnosis. International
journal of surgery case reports. 2011; 2(6):141-143

Clinical Vignetts-Small Intestine/Unclassified. American Journal of Gastroenterology
2009; 104:S257-S287







References