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Diagnose.....

Discussion in 'Spot Diagnosis' started by Xerxles, Nov 14, 2012.

  1. Xerxles

    Xerxles Well-Known Member

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    A 28-year-old man presented with intolerable epigastric pain after eating dinner. The pain was sudden in onset and accompanied by bilious vomiting. What is the diagnosis?
     

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  2. neo_star

    neo_star Moderator

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    Although the history is also classical for biliary colic, i think the ct points to a midgut volulus.

    A transverse section could hav pointed to the 'whirl sign' which is pathognomic.

    [​IMG]

    Assuming it's a mid-gut volvulus, what predisposes to a mid-gut volvulus and which artery-vein pair is compromised ?
     

    Last edited: Nov 15, 2012
  3. soha azab

    soha azab Famous Member

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    insufficient ct cuts a muticystic mass is seen between the stomach and spleen ? pancreatic also two cysts seen at epigastrium
     

  4. Xerxles

    Xerxles Well-Known Member

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    Midgut volvulos in adults maybe due to inadequete support of the intestine by the mesentery ie long mesentery , also
    Maybe due to constipation or eating large meals.

    Superior mesenteric artery and vein ....

    ??????????
     

  5. Xerxles

    Xerxles Well-Known Member

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    I will give Possible answers try to figure it out:

    Acute mesenteric ischemia
    Gastric carcinoma
    Intra-abdominal hernia
    Retroperitoneal fibrosis
    Tricobezar
     

  6. elkana

    elkana Famous Member

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    Intra- abdominal hernia? Due to acute decline of stutus after eating, plus vomiting bille...
     

  7. neo_star

    neo_star Moderator

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    Intraabdominal hernia - left sided, paraduodenal type.

    In left-sided paraduodenal hernias, small-bowel loops herniate into an unusual fossa to the left of the duodenum referred to as the paraduodenal fossa, or Landzert’s fossa, that results from a congenital defect in the descending mesocolon. This abnormal peritoneal pocket is bordered anteriorly by a peritoneal fold overlying the inferior mesenteric vein and ascending left colic artery.


    Proximal small-bowel loops, duodenal segments, or even, in rare cases, distal ileal segments enter posteriorly through the mesocolic defect, become entrapped in the Landzert’s fossa, and then extend further in the descending mesocolon.

    P.S: mesentric ischemia can happen secondary to strangulation.

     

    Last edited: Nov 15, 2012
  8. dr.angela

    dr.angela Bronze Member

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    Volvulous
     

  9. Xerxles

    Xerxles Well-Known Member

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    Neo Star Congrats......your answer is excellent.....
     

  10. neo_star

    neo_star Moderator

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    thanks, I will expand on this topic as it is imp in the context of laproscopic surgery as well, where in we create many mesentric pockets and may not sew it shut b4 concluding the surgery.

    An internal abdominal herniation is the protrusion of an abdominal organ through a normal or abnormal mesenteric or peritoneal aperture.

    → Internal abdominal herniations can be either acquired through a trauma or surgical procedure (iatrogenic internal abdominal herniations) or constitutional and related to congenital peritoneal defects.

    [TABLE="class: MsoTableGrid"]
    [TR]
    [TD] The classifications of internal abdominal herniations devised by Ghahremani is now well accepted. According to this classification system, internal abdominal herniations can be separated in six main groups (Fig. 1

    paraduodenal hernias (50”“55% of internal abdominal herniations),

    hernias through the foramen of Winslow (6”“10%),
    transmesenteric hernias (8”“10%),

    pericecal hernias (10”“15%),
    intersigmoid hernias (4”“8%), and
    paravesical hernias (< 4%). [/TD]
    [TD="width: 354"] 01.jpg [/TD]
    [/TR]
    [/TABLE]


    Paraduodenal Hernias

    Two types of paraduodenal hernias must be distinguished: left-sided paraduodenal hernias, which account for 75% of all paraduodenal hernias, and right-sided paraduodenal hernias,which account for the remaining 25%.

    02.jpg

    Left-Sided Paraduodenal Hernias
    In left-sided paraduodenal hernias (Fig. 2), small-bowel loops herniate into an unusual fossa to the left of the duodenum referred to as the paraduodenal fossa, or Landzert’s fossa, that results from a congenital defect in the descending mesocolon. This abnormal peritoneal pocket is bordered anteriorly by a peritoneal fold overlying the inferior mesenteric vein and ascending left colic artery.

    Proximal small-bowel loops, duodenal segments, or even, in rare cases, distal ileal segments enter posteriorly through the mesocolic defect, become entrapped in the Landzert’s fossa, and then extend further in the descending mesocolon.

    Radiographic ndings of left-sided paraduodenal hernias are well correlated to the anatomic topography. On barium examinations, the typical nding is the presence of a mass of agglomerated small-bowel loops just lateral to the fourth portion of the duodenum (Fig. 3) that is separated from the remaining bowel loops and shows signs of obstruction (dilatation of small bowel loops or barium stasis) (Fig. 3).

    [​IMG]

    Right-Sided Paraduodenal Hernias

    Right-sided paraduodenal hernias are congenital disorders that may be related to the incomplete or absent 180° rotation of the embryologic midgut.

    Thus, the proximal portion of the small bowel remains positioned to the right of the superior mesenteric artery and may possibly be trapped in a peritoneal pocket within Waldeyer’s fossa. This abnormal peritoneal recess, which is caused by a defect in the proximal jejunal mesentery, is rare, observed in no more than 1% of the population at autopsy.

    In right-sided paraduodenal hernias, the entrapped small-bowel loops protrude through this peritoneal recess behind the superior mesenteric artery toward the right-sided mesocolon (Fig. 6).

    [​IMG]

    In right-sided paraduodenal hernias, clustered and dilated small-bowel loops are located just lateral and inferior to the second portion of the duodenum (Fig. 7).






    The typical clinical presentations of right and left-sided paraduodenal hernias are similar; however, both conventional barium studies and CT can be used to distinguish between the two.

    Intersigmoid Hernias

    Intersigmoid hernias develop when herniated viscera protrude into a peritoneal pocket formed between two adjacent sigmoid segments and their mesentery, the intersigmoid fossa. Radiographic features of intersigmoid hernias include ileal segments herniated between sigmoid loops.

    Some authors believe that intersigmoid hernias should be distinguished from both transmesosigmoid hernias and intramesosigmoid hernias.
    In transmesosigmoid hernias, segments of the small bowel herniate through a complete defect of the sigmoid mesentery and become encased in a location lateral to the sigmoid.
    In intramesosigmoid hernias, an incomplete defect of the mesentery causes a herniation of small-bowel segments through the mesosigmoid.

    No clear radiographic sign allows one to distinguish among the three types of intersigmoid hernias, and no precise radiologic differentiation is required because surgical exploration of these hernias is mandatory.


    Transmesenteric Hernias

    Although accounting for only 5”“10% of internal abdominal herniations overall, transmesenteric hernias are the leading cause of internal abdominal herniations in children. Most transmesenteric hernias in children result from a congenital defect in the small-bowel mesentery close to the ileocecal region, whereas in adults, transmesenteric hernias are most often caused by previous surgical procedures.
    In all cases oftransmesenteric hernias, no hernial sac can beidentied, so distinguishing between a transmesenteric hernia and a small-bowel volvulus canbe difcult.
    A recent review has highlighted the high incidence of transmesenteric hernias after abdominal surgery, especially after the creation of a Roux-en-Y anastomosis .
    Clinical symptoms often include signs of acute small-bowelobstruction . Radiologic features include the classic “closed loop” sign reported by Ghahremani.


    Paravesical Hernias

    Supravesical hernias, although rare, are the cause of most pelvic hernias.
    Herniation occurs in the supravesical fossa between the remaining segments of the medial, right, or left umbilical segments. Herniated bowel loops can either remain within or extend above the pelvis. Hernias protruding through the broad ligament are
    frequently observed in older patients, and most often involve ileal segments. CT is currently the best imaging technique for detecting these particular hernias


    Conclusion

    Internal abdominal herniations are rare conditions caused by congenital mesenteric defects or abnormal embryologic development including small-bowel malrotation.
    Typical clinical presentation for all forms of internal abdominal herniations is identical, but prompt diagnosis is mandatory because small-bowel damage, ischemia, and necrosis can result from misdiagnosis and consequent delay in proper treatment.
    CT allows physicians to make a precise anatomic diagnosis and to identify acute complications; therefore, we highly recommended obtaining CT scans before laparoscopy is performed.
     

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  11. neo_star

    neo_star Moderator

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    The intra-abdominal hernia led to the vomiting and acute decline of status ( and not the other way ). This person was possibly born with this abnormal mesentric pocket and the intestines ware always hanging around the mouth of this mesentric pocket and he must have had many occasions where in following a meal the intestines may have transiently herniated into the pouch (courtesy the gastro-colic reflex following a meal ), but returned back with some mild colicky symptoms. This time he wasn't that lucky and the peristalsis carried the intestines too far into the pouch causing an acute obstruction.

    Superb case by Xerxles !!!
     

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