RAdiology of internal hernia

1. Radiology of the internal hernia
Gastrointestinal
imaging
Presented by :
Dr.Ahmed Abdelkarim, MD

2. Radiology of the internal hernia
Definition
&
classificati
on
How to
diagnose
Small
bowel
related
hernia
Large
bowel
related
hernia
Omentum
related
hernia
Others
Differential
diagnosis
General principles Types DD

3. Radiology of the internal hernia
Definition &
classification
How to
diagnose
General principles

4. Radiology of the internal hernia
 Definition
 Protrusion of bowel loops through a peritoneal defect
 Peritoneal defect = Hernia orifice
 Most common signs/symptoms
 Asymptomatic
 Intermittent abdominal pain
 Symptoms of acute small bowel obstruction
 Nausea, vomiting, abdominal pain, and abdominal distention

5. Radiology of the internal hernia
 Normal foramen
 Foramen of Winslow hernia
 Unusual retroperitoneal recess / fossa
 Paraduodenal hernia
 Pericecal hernia
 Intersigmoid hernia
 Most types of pelvic internal hernia
 Abnormal opening in a mesentery or peritoneal ligament
 Small bowel mesentery related hernia
 Transverse mesocolon related hernia
 Sigmoid mesocolon related hernia
 Greater omentum related hernia
 Most types of lesser sac hernia
 Falciform ligament hernia
 Broad ligament hernia
Mechanism & Classification
of the internal hernia
According to the
peritoneal
defect/hernia
orifice

6. Radiology of the internal hernia
 Closed-loop obstruction
 A segment of the bowel is occluded at two adjacent points.
 Type of bowel obstruction seen in the internal hernia.
 Can be seen in other conditions ”volvulus , adhesion ”.
 Can easily develop into intestinal strangulation and ischemia
How to Diagnose

7. Radiology of the internal hernia
 A direct sign of a closed loop at CT
 U- or C-shaped, fluid-filled, distended intestinal loop,
 Radial distribution of stretched and thickened mesenteric vessels toward hernia orifice
Best diagnostic
clue

8. Radiology of the internal hernia
 Saclike appearance
 Sacculation and crowding of small bowel loops owing to encapsulation within the hernia sac
 Seen in unusual fossa in the retroperitoneum or intramesenteric-type internal hernia
Best diagnostic
clue

9. Radiology of the internal hernia
 Displacement of surrounding structures and key vessels
Best
diagnostic clue

10. Radiology of the internal hernia
Small bowel
related hernia
Large bowel
related hernia
Omentum
related hernia
Others
Types

11. Radiology of the internal hernia
Small bowel
related hernia
Small bowel
mesentery
related hernia
Paraduodenal
hernia
Types

12. Paraduodenal Hernia
 Definition
 Protrusion of the small intestine into a retroperitoneal fossa near duodenum
 Types ; Right and left
 Left paraduodenal hernias are
approximately three times more common
than right paraduodenal hernias

13. Paraduodenal Hernia
 Left paraduodenal hernia
 Saclike appearance is observed in the left anterior pararenal space
 IMV is anteriorly displaced and seen along medial border of sac
Best diagnostic
clue

14. Paraduodenal Hernia
 Right paraduodenal hernia
 A saclike appearance is seen right anterior pararenal space
 Inferior and to the right of 3rd par of the duodenum
 SMV anteriorly displaced and seen along medial border of sac
Best
diagnostic clue

15. Paraduodenal Hernia
 Asymptomatic /incidentally discovered cases of paraduodenal hernia can be seen.

16. Small bowel mesentery related hernia
 Definition
 Protrusion of the small intestine through defect within small bowel mesentery
 Types ;
 Transmesentreic = Most common type ,involve two layer of peritoneal folds
 Intramesenteric = mesenteric pouch (rare)

17. Small bowel mesentery related hernia
 Signs of closed loop obstruction
 Can be seen at the upper or lower abdomen.
 Congested crowded mesenteric vessels toward the mesentery.
 Hernia orifice near the terminal ileum or near the ligament of Treiz
Best diagnostic
clue
Transmesenteric type
No sac like configuration

18. Small bowel mesentery related hernia
 Displacement of the main mesenteric trunk to the right

19. Small bowel mesentery related hernia
 High incidence of strangulation

20. Radiology of the internal hernia
Large bowel
related hernia
Sigmoid
mesocolon
related hernia
Pericecal
related hernia
Types

21. Pericecal internal hernia
 Definition
 Protrusion of bowel into an unusual recess near the cecum.
 Types
 Four kinds of pericecal recesses have been defined:
 Superior and inferior ileocecal recess, retrocecal recess, and paracolic sulcus

22. Pericecal internal hernia
 Saclike appearance is seen
 Lateral to the cecum & ascending colon ”Right Para-colic gutter”.
 Displaces the cecum and ascending colon anteriorly or medially.
Best
diagnostic clue

23. Sigmoid Mesocolon–related Hernia
 Definition
 Herniation of the bowel through the sigmoid mesentery
 Types
 Three subtypes transmesosigmoid, intramesosigmoid, and intersigmoid

24. Sigmoid Mesocolon–related Hernia
 Sac like appearance or closed loop obstruction can be present
 At the left iliac fossa region along the left side of the descending colon ”LT Paracolic gutter”.
 Hernia orifice is seen between the psoas muscle and sigmoid colon.

25. Radiology of the internal hernia
Omentum related
hernia
Lesser sac
related hernia
Greater
Omentum
related hernia
Types

26. Greater omentum related internal hernia
 Definition
 Protrusion of the bowel loops through defect within greater omentum
 Type
 The herniated intestine passes through both leaves (ie, four peritoneal layers)

27. Greater omentum related internal hernia
 Signs of closed loop obstruction
 Bowel loops close to anterior abdominal wall and inferior to the transverse colon
 Omental vessels are seen displaced anteriorly
Best diagnostic
clue

28. Lesser sac related internal hernia
 Definition
 Protrusion of the bowel loops within the lesser sac.
 Types : 4 (most common FOW hernia)

29. Lesser sac related internal hernia
 Sign of closed loop obstruction
 Seen in the lesser sac between stomach and pancreas
 Hernia orifice is between portal vein and IVC
Best
diagnostic clue

30. Radiology of the internal hernia
Others
Broad
ligament
related hernia
Falciform
ligament
related hernia
Types

31. Falciform ligament related internal hernia
 Definition
 Protrusion of bowel loops through defect within the Falciform ligament
 Vere rare type

32. Falciform ligament related internal hernia
 Closed loop obstruction
 Related to or just inferior to the anterior surface of the liver
 Paraumbilical vein represent the inferior land mark of the ligament

33. Broad ligament related internal hernia
 Definition
 Protrusion of the bowel through defect within the broad ligament
 Types
 Pouch type = Intramesenteric type
 Fenestra type = Transmesenteric type

34. Broad ligament related internal hernia
 Closed loop or sac like appearance of bowel loops
 Seen at the pelvis
 Hernia orifice is seen directed toward the Parametrium
 Enlargement of the distance between the uterus and ovary, deviating in opposite directions
 key vessels
 Tubal and ovarian branches of the ovarian artery (run inside the superior portion of the ligament).
 The uterine artery and venous plexus,( run along the inferior border of the broad ligament)
Best diagnostic
clue

35. Radiology of the internal hernia
Differential
Diagnosis
DD

36. Radiology of internal hernia
 Small bowel volvulus
 Swirl signs
 Adhesion
 History of operation
 After exclusion of other
Differential
Diagnosis
Internal
hernia
Adhesion
Volvulus
Closed loop obstruction

37. Paraduoden
al internal
hernia
Small bowel
mesentery
internal
hernia
Pericecal
internal
hernia
Greater
omentum
internal
hernia
Sigmoid
mesocolon
internal
hernia
FOW
internal
hernia
others