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Year : 2019 | Volume : 7 | Issue : 1 | Page : 25 - 26  


Case Reports
Transmesenteric hernia: A rare cause of bowel obstruction in pregnancy

Laxmana Sastry1, Sandeep Reddy2, Malyadri3, Karthik Chandra4

1Consultant Surgeon, 2DNB Residents, Yashoda Hospital, Secunderabad

*Corresponding Author

Email: laxmanags@yahoo.com

Summary: 

Complete bowel obstruction caused by an internal hernia is rare non-obstetric cause of abdominal pain. Delay in diagnosis, due to non-specific signs and symptoms, present in normal pregnancy, and reluctance to operate on the pregnant patient leads to fatal outcome including fetal loss.

Keywords: Transmesenteric hernia; Small bowel obstruction; Pregnancy

Introduction:

Transmesenteric herniae are a rare cause of bowel obstruction in pregnancy. It constitutes (5-10%) of all internal hernia. [1]. A Transmesenteric hernia is a congenital defect in the mesentery, and can present at any age. [2] The cause may be prenatal intestinal ischemia and subsequent thinning of the mesenteric leaves. A genetic etiology has been suggested in association with cystic fibrosis and Hirschprung disease. 

CASE REPORT: 

A 24-year-old female, at 17 weeks gestation presented with a one-day history of sudden onset, abdominal pain, vomiting and constipation. On examination, she was hemodynamically stable and febrile with generalized abdominal tenderness and guarding. Bowel sounds were absent. Fundal height was consistent with 17-week gravid uterus and fetal heart sounds were present. Her pregnancy until this point was uneventful with no significant past medical history.

Investigations revealed Hb-6.6gm%, TLC-22,150 cells/cu mm, platelet count-2.20 lakh/cu mm, serum amylase-30 U/dl; LFT &RFT are normal.

Ultrasound revealed distended loops of bowel with free fluid in the abdomen and pelvis; ascitic fluid tap revealed reddish color turbid fluid. She was treated with anti-emetics, analgesics, intravenous antibiotics, intravenous fluids and blood transfusions. She had increasing abdominal distension, developed pyrexia, and on suspicion of gangrene small bowel a decision for emergency laparotomy was made with informed consent, including risk of fetal loss.

At laparotomy hemorrhagic fluid & approximately 130 cm of gangrenous jejunum and proximal ileum herniating through a mesenteric defect (see Fig. 1&2). The hernia was reduced, gangrenous small bowel resected and end illeostomy was performed. Patient made a good recovery and was discharged from hospital 5 days later. Histopathology revealed hemorrhagic infarction of 130 cm of small bowel and mesenteric vessels showed no evidence of vasculitis or thrombosis.

Fig. 1

Fig. 2: Gangrenous bowel evident herniating through small bowel mesenteric defect 

DISCUSSION: 

Patients with acute abdomen in pregnancy are diagnostically challenging.

Preoperative diagnosis of Transmesenteric herniae is difficult due to a lack of specific radiological or laboratory findings. Increased steroid levels may suppress any natural inflammatory responses. Misdiagnosis and subsequent delayed exploration may lead to bowel ischemia and subsequent mortality, prognosis being directly correlated with the delay in diagnosis and treatment.

 The first choice of abdominal imaging in pregnancy is ultrasound. However, complex cases need MRI.  MRI gives excellent soft tissue contrast, multiplanar imaging and avoids risks of radiation exposure to the foetus.MRI is a useful confirmatory test for small bowel obstruction in pregnancy. [3]

 However, even if findings of imaging are unremarkable surgical exploration should not necessarily be delayed, when there is strong clinical suspicion, as internal hernias can be present with non-specific symptoms.

A retrospective review in Mississippi between 1970 and 1983 identified 8 patients with small bowel obstruction secondary to congenital internal herniation of which 5 patients had developed gangrenous bowel.

A 10 year retrospective review of management of internal hernia in Taiwan 6 patients suffering from Transmesenteric herniae were identified, with rebound tenderness, advanced leucocytosis (>18,000 cells/cu mm) and a high level of manual band form (>6%) being identified as positive predictive factors for bowel ischemia. [4]

The most common non-obstetric surgical diagnosis in a pregnant woman is appendicitis (1:1250–1500) 50% of them happen in second trimester. By comparison, small bowel obstruction in the pregnant population is rare (1:17,000).Idiopathic transomental herniation is extremely rare, (1–4%). [5]

Intra-abdominal small bowel herniation is a recognized complication from bariatric surgery and it may be due to the changes associated with pregnancy that make Herniation more likely. [6] 

CONCLUSION:

We report a rare case of a 24-year-old female with a spontaneous Transmesenteric hernia of jejunum and proximal ileum with associated gangrene of bowel caused by a mesenteric defect. The insidious onset of this surgical emergency reaffirms the importance of surgeons maintaining a high index of suspicion for a Transmesenteric hernia in patients with non-specific clinical and radiological signs. Close monitoring of the patients general condition in cases of non-specific abdominal pain is essential to identify the rare deteriorating patient for early surgical intervention and optimal outcome. 

REFERENCES: 

  1. Malit M, Burjonrappa S. Congenital mesenteric defect: description of a rare cause of distal intestinal obstruction in a neonate. International J Surg Case Rep 2012;3:121–123. 
  2. Gyedu A, Damah M, Baidoo PK, Yorke J. Congenital Transmesenteric defect causing bowel strangulation in an adult. Hernia. 2010;14:643–645. 
  3. McKenna D.A., Meehan CP. The use of MRI to demonstrate small bowel obstruction during pregnancy. Br J Radiol. 2007;80:e11–e14
  4. Fan HP, Yang AD, Chang YJ, Juan CW, Wu HP. Clinical spectrum of internal hernia: a surgical emergency. Surg Today. 2008;38:899–904.
  5. Ariyarathenam AV, Tang TY, Nachimuthu S. Transomental defects as a cause of chronic abdominal pain, the role of diagnostic laparoscopy: a case series. Cases J. 2009;2:8356
  6. Kakarla N, Dailey C, Marino T. Pregnancy after gastric bypass surgery and internal hernia formation. Obstet Gynecol. 2005;105:98




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