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Table of Contents
CASE REPORT
Year : 2018  |  Volume : 15  |  Issue : 1  |  Page : 35-37

Congenital mesenteric defect causing volvulus and intestinal obstruction in an adult


Department of GI Surgery, Indraprastha Apollo Hospital, New Delhi, India

Date of Web Publication2-Apr-2018

Correspondence Address:
Adithya GK
Department of GI Surgery, Indraprastha Apollo Hospital, Mathura Road, Sarita Vihar, New Delhi - 110 076
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/am.am_20_17

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  Abstract 

A 39-year-old female presented with a history of recurrent pain abdomen for 2 years. The pain was colicky and intermittent in nature. She had been diagnosed to have right-sided nephrolithiasis based on the findings of computed tomography (CT) abdomen and was managed conservatively during each episode of pain. During the present episode, her pain started 4 days prior to presentation and was associated with vomiting and inability to pass stool and flatus. X-ray abdomen showed evidence of dilated bowel loops. On clinical examination, her abdomen was distended with tenderness and guarding in the right lower abdomen. Her CT abdomen revealed dilated ileal loops in the right lower abdomen. The distal bowel was found to be collapsed. On exploratory laparotomy, a volvulus of the distal ileum, caecum and part of ascending colon was noted. The involved bowel loops were gangrenous. A mesenteric defect of about 10 cm was noted in the root of the mesentery, which had caused an internal herniation, volvulus and gangrene. She underwent a right hemicolectomy with covering ileostomy. Congenital mesenteric defects leading to internal herniation are a well-documented condition in pediatric population. Although the same can occur in adults, it is an infrequent cause of intestinal obstruction.

Keywords: Adult volvulus, congenital, intestinal obstruction, mesenteric defect


How to cite this article:
GK A, Jindal SP, Madaan V, Tandon V, Govil D. Congenital mesenteric defect causing volvulus and intestinal obstruction in an adult. Apollo Med 2018;15:35-7

How to cite this URL:
GK A, Jindal SP, Madaan V, Tandon V, Govil D. Congenital mesenteric defect causing volvulus and intestinal obstruction in an adult. Apollo Med [serial online] 2018 [cited 2022 Jan 19];15:35-7. Available from: https://www.apollomedicine.org/text.asp?2018/15/1/35/229054


  Introduction Top


Internal herniation of small bowel is a well-known congenital condition in childhood, causing small bowel obstruction. It is a rare cause of intestinal obstruction ranging in incidence from 0.5% to 4.1%.[1] Based on location, hernias can be paraduodenal, pericecal, Winslow's foramen, transmesenteric, pelvic, intersigmoid, supravesical and rarely omental. Paraduodenal hernias are most commonly reported.[2] Patients presenting in adult age group is quite rare, posing a diagnostic difficulty preoperatively. Fifty percent of the recent studies have shown volvulized transmesenteric hernias increasing the associated mortality.[3]


  Case Report Top


A 39-year-old female presented with a history of recurrent pain abdomen for 2 years. The pain was colicky and intermittent in nature. She had been diagnosed to have right-sided nephrolithiasis based on the findings of computed tomography (CT) abdomen and was managed conservatively during each episode of pain. During the present episode, she had pain 4 days prior to the presentation and was associated with vomiting and inability to pass stool and flatus for 3 days. On clinical examination, her abdomen was distended with tenderness all over and guarding in the right lower abdomen. X-ray abdomen showed evidence of dilated bowel loops mainly on the left side of the abdomen. CT abdomen [Figure 1] and [Figure 2] showed dilated ileal loops in the right lower abdomen and collapsed distal bowel. There was no evidence of pneumoperitoneum or peritonitis. In view of unsettled obstruction, she was planned for surgery. On exploratory laparotomy, minimal ascites were noted. The dilated distal ileum was traced till ileoceal junction, and a volvulus of the distal ileum, caecum, and part of ascending colon was noted. The involved bowel loops were gangrenous. A mesenteric defect of about 10 cm in size was noted in the root of the mesentery, which had caused an internal herniation, volvulus, and gangrene [Figure 3], [Figure 4], [Figure 5], [Figure 6]. A right hemicolectomy with covering ileostomy was performed. The patient was discharged on postoperative day 5 with soft diet. She was planned for ileostomy closure at the end of 4 weeks after getting a check distal loopogram. The patient underwent side-to-side stapled ileostomy closure [Figure 7]. The patient was discharged on postoperative day 5 with soft diet. On follow-up after 2 weeks, she was doing well with adequate calorie and protein intake.
Figure 1: Contrast-enhanced computed tomography abdomen showing thickened right colon with air bubbles in the intra- and extra-mural space

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Figure 2: Mass formation in the right iliac fossa (volvulus)

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Figure 3: Large mesenteric defect

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Figure 4: Large mesenteric defect with internal hernia of distal ileum and arge bowel causing volvulus

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Figure 5: After specimen is being excised

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Figure 6: Excised specimen

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Figure 7: Side-to-side anastomosis of healthy bowel with stapler

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  Discussion Top


Congenital mesenteric defect is a rare entity causing intestinal obstruction. Awareness of this condition puts the surgeon on better grounds to tackle the condition at surgery. An internal hernia occurring through this is still rarer. As no hernial sac is involved, a considerable length of bowel can pass through the defect.[4],[5] Transmesenteric hernias are most commonly located in the ileocecal region; however, there are reports of herniation through defects in the sigmoid mesocolon also.[6] Overall, congenital transmesenteric hernias constitute only 5%–10% of internal hernias. Thirty percent of the cases remain asymptomatic.[6] The first case of transmesenteric hernia was reported in 1836 at autopsy. Most cases are reported in the pediatric age group. The exact etiology is not known. Proposed hypotheses are regression of the dorsal mesentery, developmental enlargement of a hypovascular area, the rapid lengthening of a segment of mesentery, and compression of the mesentery by the colon during fetal mid-gut herniation into the yolk sac.[7] Less severe vascular accidents cause mesenteric defects without atresia, while the more severe ones lead to mesenteric defects and atresia.[8]

Patients usually present with an acute abdomen with signs of distal or proximal bowel obstruction depending on the site of herniation. X-ray abdomen only shows dilated bowel with air–fluid levels. Contrast-enhanced CT (CECT) abdomen is preferable in adults and gives information about the site of obstruction and viability of bowel. In our case, CECT abdomen showed dilated ileal loops in the right lower abdomen and collapsed distal bowel. Most cases are diagnosed intraoperatively on laparotomy. Large defects are seen in the mesentery or mesocolon and small or large bowel passes in and out of the defect causing obstruction or strangulation. Intermittent movement of the bowel through the defect may sometimes give on-and-off abdominal pain until it becomes fully obstructed. In this scenario, chronic intussusception is also a differential diagnosis.

The exact surgical treatment depends on the viability of bowel. Volvulus and ischemia are more common in transmesenteric hernias as compared to other internal hernias.[9],[10] It is imperative to inspect the bowel starting from the ligament of Treitz and follow it throughout the full length of the bowel. Simple untwisting or reduction of the bowel and closure of the mesenteric defect are warranted if the bowel appears viable or else resection with either a primary anastomosis or stoma should be performed.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.


  Conclusion Top


Congenital mesenteric defect being rare in adults is difficult to diagnose preoperatively. If detected intraoperatively, every effort should be made to repair the defect completely. Nonviable bowel should be resected and healthy ends should be anastomosed or a stoma should be created depending on the condition of the remaining intestine.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
  References Top

1.
Blachar A, Federle MP, Dodson SF. Internal hernia: Clinical and imaging findings in 17 patients with emphasis on CT criteria. Radiology 2001;218:68-74.  Back to cited text no. 1
[PUBMED]    
2.
Selçuk D, Kantarci F, Oǧüt G, Korman U. Radiological evaluation of internal abdominal hernias. Turk J Gastroenterol 2005;16:57-64.  Back to cited text no. 2
    
3.
Hashimoto D, Hirota M, Sakata K, Yagi Y, Baba H. Adult transmesenteric hernia: Report of two cases. Surg Today 2012;42:489-92.  Back to cited text no. 3
    
4.
Ghahremani GG. Internal abdominal hernias. Surg Clin North Am 1984;64:393-406.  Back to cited text no. 4
    
5.
Winterscheid LC, Nyhus LM, Harkins HN. Mesenteric hernia. Hernia. Philadelphia: JB Lippincott; 1964. p. 602-5.  Back to cited text no. 5
    
6.
Weber P, Von Lengerke HJ, Oleszczuk-Rascke K, Schleef J, Zimmer KP. Internal abdominal hernias in childhood. J Pediatr Gastroenterol Nutr 1997;25:358-62.  Back to cited text no. 6
    
7.
Federschmidt F. Embryonal origin of lacunae in mesenteric tissue; the pathologic changes resulting therefrom. Dtsch Z Chir 1920;158:205-11.  Back to cited text no. 7
    
8.
Malit M, Burjonrappa S. Congenital mesenteric defect: Description of a rare cause of distal intestinal obstruction in a neonate. Int J Surg Case Rep 2012;3:121-3.   Back to cited text no. 8
    
9.
Janin Y, Stone AM, Wise L. Mesenteric hernia. Surg Gynecol Obstet 1980;150:747-54.  Back to cited text no. 9
    
10.
Vaos G, Skondras C. Treves' field congenital hernias in children: An unsuspected rare cause of acute small bowel obstruction. Pediatr Surg Int 2007;23:337-42.  Back to cited text no. 10
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7]



 

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