History: 32 yo female with acute onset abdominal pain and vomiting. Only mdical history is a history of morbid obesity with bariatric surgery about 3 months prior.
Solution: Internal hernia after gastric bypass surgery
This case is a test of your abdominal plain film interpretation skills. On the plain films, you can clearly see a grouping of dilated small bowel in the mid abdomen displacing the transverse colon inferiorly. The remainder of the small bowel and colon are not dilated and you should be suspiscious of a closed loop obstruction. There are also surgical changes in the LUQ (subtle, but present), which would be consistent with a gastric bypass. This combination of findings is very suspiscious for an internal hernia after gaastric bypass. The CT is diagnostic and has much more obvious findings.
Closed loop obstructions are the most common cause of bowel strangulation. They are most frequently secondary to adhesions, but can also be seen in the setting of an incarcarated hernia of many different types including an internal hernia. An internal hernia is the herniation of bowel through a developmental or surgical defect of the peritoneum, omentum, mesentery or though an adhesive band. They can be retroperitoneal or anteperitoneal. It is becoming increasingly obvious that patients are at increased risk for internal hernias following a laparoscopic Roux-en-y gastic bypass for morbid obesity. There appears to be approximately 5% risk for this complication. It occurs at the level of the mesocolic window, likely because the associated sutures fail and a defect develops.
This case is a test of your abdominal plain film interpretation skills. On the plain films, you can clearly see a grouping of dilated small bowel in the mid abdomen displacing the transverse colon inferiorly. The remainder of the small bowel and colon are not dilated and you should be suspiscious of a closed loop obstruction. There are also surgical changes in the LUQ (subtle, but present), which would be consistent with a gastric bypass. This combination of findings is very suspiscious for an internal hernia after gaastric bypass. The CT is diagnostic and has much more obvious findings.
Closed loop obstructions are the most common cause of bowel strangulation. They are most frequently secondary to adhesions, but can also be seen in the setting of an incarcarated hernia of many different types including an internal hernia. An internal hernia is the herniation of bowel through a developmental or surgical defect of the peritoneum, omentum, mesentery or though an adhesive band. They can be retroperitoneal or anteperitoneal. It is becoming increasingly obvious that patients are at increased risk for internal hernias following a laparoscopic Roux-en-y gastic bypass for morbid obesity. There appears to be approximately 5% risk for this complication. It occurs at the level of the mesocolic window, likely because the associated sutures fail and a defect develops.
Radiograph Images
