Hans Belly-Pain Small bowel obstruction, internal hernia

Personal story

Hans Belly-Pain is a young man in his early thirties working as a carpenter. Born Hans Belly, he found his love Linda Pain during a hiking tour in the mountains. Married in the meantime, they enjoyed their lives in their small house in a village in southern Styria, one exceptionally beautiful province of Austria.

Linda and Hans have celebrated their one-year marriage anniversary with a delicious dinner in one of the famous “Buschenschank” near their home, eating plenty of beans and beef with raw onions and pumpkinseed oil and enjoying a glass of Schilcher or two.

The next morning Hans started to feel unwell with strong abdominal pain and had to vomit. Linda was worried, as was Hans, and as the pain did not subside but grew even stronger over the next hours, they decided to see the emergency department of the University Hospital in Graz.

The doctors were also worried when they found Hans screaming in agonizing abdominal pain and they ordered a CT of the abdomen. As the CT showed a closed-loop obstruction due to a left paraduodenal hernia, Hans was immediately transferred to the operating theatre, where large parts of his small bowel were found to be necrotic and had to be removed.

Hans recovered well, however developed mild symptoms of a short bowel syndrome. He suffers from intermittent abdominal pain since the operation, however, this has been self-limiting so far with no signs of recurrent bowel obstruction.

Now, almost one year later, Hans has returned to normal life, doing what he loves, working with wood and spending time with Linda, his beloved wife.

Radiological Findings

Bowel obstruction most commonly affects the small intestine. The most frequent cause of small bowel obstruction in developed countries is adhesions (1). In 24% the small bowel obstruction does not resolve without surgery (2). A special type of bowel obstruction is a closed-loop obstruction, which is caused by obstruction of a bowel loop at two points, commonly due to strangulation (Figure 1). It can be caused by adhesions, torsion, abdominal wall hernia or internal herniations. The latter can occur in several locations, often facilitated by previous operations or anatomical variants (3).

A CT scan can depict typical signs of bowel obstruction, such as dilated bowel loops (4). Figure 2 shows a CT image that depicts the affected small bowel shown as hypoattenuating (dark) loops (a) in contrast to adjacent normal, collapsed small bowel loops (b), a sign of decreased perfusion. There is stranding of the affected mesentery and distended mesenteric veins (c) indicating venous congestion. Also, the entry of one bowel limb into the hernial sac can be appreciated (d). There is also an exiting limb (not depicted). These are typical signs of a closed-loop obstruction. The bowel dilation typically seen in bowel obstruction was not pronounced in this case. Figure 3 additionally shows that the descending colon (b) is ventrally displaced, compressed against the abdominal wall and located ventrally to the apparent herniation sac (a), indicating a left paraduodenal hernia. In this case, the location of obstruction next to the Treitz ligament and the atypical position of the affected bowel loops dorsal to the descending colon (thus in a retroperitoneal location) indicate a left paraduodenal hernia.

Closed-loop obstruction with signs of vascular compromise is an emergency that must be surgically treated without delay.

Author: Johannes Schmid, MD, PhD, Radiology Consultant, Medical University of Graz, Graz, Austria. [email protected]

References

1. Merril T. Dayton, Daniel T. Dempsey, Gerald M. Larson, Alan R. Posner. New Paradigms in the Treatment of Small Bowel Obstruction. Current Problems in Surgery. 2012; 49(11): 642-717. doi: 10.1067/j.cpsurg.2012.06.005.
2. Foster NM, McGory ML, Zingmond DS, et al. Small bowel obstruction: a population-based appraisal. J Am Coll Surg 2006;203(2):170–6.
3. Katie Love Bower, Daniel I Lollar, Sharon L Williams, Farrell C Adkins, David T Luyimbazi, Curtis E Bower. Small Bowel Obstruction. Surg Clin North Am. 2018 Oct;98(5):945-971. doi: 10.1016/j.suc.2018.05.007. Epub 2018 Aug 7.
4. Erik K Paulson, William M Thompson. Review of small-bowel obstruction: the diagnosis and when to worry. Radiology. 2015 May;275(2):332-42. doi: 10.1148/radiol.15131519.