A transmesenteric congenital internal hernia presenting in an adult
A 32-year-old man undergoing treatment for a depression with serotonin–norepinephrine reuptake inhibitors (SNRIs) and with one prior admission to the hospital due to rightsided abdominal pain was admitted to our department after 4 h with severe abdominal pain. The pain was acute in onset, stabbing and located in the whole right side of the abdomen, radiating to the back and to the right groin. The pain was associated with nausea and restlessness, and could not be reduced with either NSAID or high doses of morphine. On presentation, he was ill looking, sweating, restless and in agony. He was ABC stable, his abdomen distended with generalized tenderness and in his upper right quadrant he had a 10 × 10-cm hard very sore mass, with positive rebound tenderness. There were normal bowel sounds.\nParaclinical tests showed leucocytosis (10,1 × 109/l) and normal serum lactate. A computed tomography (CT) scan showing gastric retention, encapsulated dilated small intestines in the right upper quadrant with pneumatosis intestinalis and collapsed small intestines distally from this area interpreted as intestinal obstruction (Figs and ).\nAn emergency laparotomy was performed 12 h after the first appearance of the symptoms and 7 h after admission to the hospital. This revealed severe small bowel obstruction. Approximately 1 m of small bowel was found distended, herniated and strangulated through a 2-cm defect in the mesentery of the transverse colon. Furthermore, it was capsuled in the mesenteric peritoneum, resembling a balloon ready to burst. The intestines were greyish in colour, but vital without signs of necrosis or ischaemia (Fig. ). The peritoneal capsule was then removed and the defect widened, before the herniated small bowel could be loosened and retracted back through the hernia. The defect was sutured. The postoperative course was smooth, and the patient was discharged 4 days later. The patient has not been readmitted to the hospital at 18 months follow-up, but did complain of mild pain in the upper abdomen the first few weeks after discharge.