A 70-Year-Old Woman With Progressive Abdominal Pain

Ehab H. Youssef, MD, FRCR


August 09, 2016


The abdominal CT images revealed a cluster of prominent bowel loops, likely jejunal, in the left upper quadrant region, lateral to the ascending duodenum pointing inwardly. The duodenum demonstrated an abrupt caliber change. Mesenteric congestion and stranding were noted. Associated mass effect was noted, with displacement of the posterior stomach wall anteriorly. Also noted was displacement of the duodenojejunal junction inferomedially and the transverse colon inferiorly (not shown). These findings were consistent with a diagnosis of paraduodenal hernia.

A paraduodenal hernia is a type of internal hernia, further classified as right- or left-sided. An internal hernia is defined as a protrusion of bowel loops through a congenital or acquired defect of the mesentery contained within the abdominal cavity. They are relatively uncommon; paraduodenal hernias are the most common type, making up 53% of all internal hernias. Internal hernias occur secondary to either a congenital defect (eg, paraduodenal) or an acquired defect (eg, following transmesenteric surgery [ie, mesocolic hernia]).

Paraduodenal hernias occur when bowel prolapses through the Landzert fossa (also known as the left paraduodenal fossa), an aperture present in approximately 2% of the population. These hernias are therefore classified as congenital internal hernias. The Landzert fossa is located behind the ascending or fourth part of the duodenum and is formed by the lifting up of a peritoneal fold by the inferior mesenteric vein and ascending left colic artery as they run along the lateral side of the fossa. Small-bowel loops prolapse posteroinferiorly through the fossa to the left of the fourth part of the duodenum into the left upper quadrant. A left paraduodenal hernia is a cluster of bowel loops in the left upper quadrant lateral to the ascending duodenum. A right paraduodenal hernia is a cluster of bowel loops that appears in the right upper quadrant region lateral and inferior to the descending duodenum.

Mesenteric vessel abnormalities, including distortion, enlargement, stretching, and anterior displacement of the main mesenteric trunks (especially the inferior mesenteric vein) to the left, are also helpful findings. Paraduodenal hernia occurs in 2%-4% of the population and usually occurs between the fourth and sixth decades of life. This condition, however, has also been reported in children, with a male predominance (male-to-female ratio, 3:1).[1,2,3,4,5,6]

Patients may be asymptomatic or may complain of vague discomfort, abdominal distention, colicky epigastralgia, or periumbilical pain. A palpable mass may be present, with local tenderness on physical examination. If a bowel obstruction exists, it is usually of a low grade, chronic, and recurrent; however, high-grade, acute, and sudden obstructions have also been found. These hernias have a propensity to reduce on their own; therefore, patients should be imaged when they do exhibit symptoms.[1,4]


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