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Congenital Mesenteric Defect: An Uncommon Cause of Bowel Obstruction
Abstract
Congenital mesenteric defects can lead to internal hernias which may result in a bowel obstruction. They are very rare among the adult population, comprising only 0.2%-0.9% incidence rate of all small bowel obstructions. A 40 year old woman presented to the Emergency Department with abdominal pain.Computed tomography scan was obtained and showed a small bowel obstruction.After failed conservative management with bowel rest and nasogastric tube decompression, the patient underwent diagnostic laparoscopy.An internal hernia was identified though a congenital mesenteric defect at the level of the sigmoid colon. The hernia was reduced and the defect closed. When a patient presents with abdominal pain the diagnosis of a congenital mesenteric defect with internal hernia should be considered with subsequent emergent surgical exploration.
... Congenital transmesenteric defect is generally 2 to 3 cm in diameter and can cause internal hernia and bowel obstruction. Patients can present at any age with abdominal pain and bowel obstruction, which is not uncommon in the pediatric population but is extremely rare in the adult population, representing 0.2 to 0.9% incidence of all small bowel obstructions in adults [12]. It is challenging to diagnose this condition pre-operatively as the transition point of bowel obstruction can be identified. ...
... Preprints (www.preprints.org) | NOT PEER-REVIEWED | Posted: 10 January 2024 doi:10.20944/preprints202401.0794.v112 ...
Mesentery was discovered as a new organ in 2017. It is a continuous membranous tissue from the duodenojejunal flexure to the anorectal junction. It has distinct anatomy, physiology, and disease states. Primary mesenteropathies include vascular and non-vascular diseases. Some of them are common, and some of them are rarely seen in clinical practice. Secondary mesenteropathies occur when infection or malignancy in another organ spreads to the mesentery. Each entity has specific diagnostic and treatment protocols.
... This condition is more commonly presented in the paediatric population but extremely rare in adults. The commonest locations of these hernia defects are close to the duodeno-jejunal flexure or the ileo-caecal junction [22][23][24][25][26][27]. In adults, the condition could be asymptomatic, or causes intermittent obstructive symptoms or present as acute MSBO with high risk of strangulation. ...
... In addition to high index of clinical suspicion, CTAP is the usual diagnostic modality in the emergency settings that can show radiological features of MSBO but often fails to identify the cause of obstruction. Therefore, the final diagnosis is not unusually confirmed intra-operatively [22][23][24][25][26][27]. ...
Mechanical small bowel obstruction in adults is a common emergency condition that typically requires hospitalisation and usually acute surgical intervention. The majority of the cases are due to adhesive obstruction or common abdominal wall hernias or relevant related past history. However, the surgeons might face unexpected challenges in this concept due to rare causes of this condition. This paper explores in depth the challenges encountered by the emergency general surgeons in the concept of management of rare causes of mechanical small bowel obstruction in adults through a systematic review and critical analysis of the available evidence, and summarises the essential intra-operative steps that are needed to be taken accordingly. In conclusion, the emergency surgeons should be familiar with the uncommon/rare causes of mechanical small bowel obstruction in adults to avoid serious complications. Successful outcomes are based on the combination of high index of clinical suspicion, familiarity with the standard anatomy and its variations, the use of the appropriate radiological investigations and surgical intervention in a timely manner.
... If the bowel is gangrenous, then resection of the segment is done. [8] However, it should be ensured that the rest of the mesentery should be explored to rule out any other defect sites. Also, any areas of potential herniation should be closed to prevent recurrences. ...
A transmesenteric internal hernia (TIH) is a protrusion of a viscus through the mesenteric defect. It is secondary to previous gastrointestinal surgery in an adult. Early diagnosis and management are warranted to prevent the strangulation of the bowel in a TIH. Here, we are reporting a case of a 24-year-old gentleman with COVID-positive status who has presented with cough, abdominal cocoon, and features of subacute intestinal obstruction (SAIO) without any previous history of abdominal surgery. A nonoperative trial is given in the management of abdominal cocoon with SAIO. In contrast, delay in surgical intervention in TIH leads to bowel gangrene. Surprisingly even on contrast-enhanced computed tomography of the abdomen, TIH was not picked up. We have diagnosed this case intraoperatively with gangrene of the bowel. In an abdominal cocoon without any history suggestive of tuberculosis or previous surgery, or any other condition that leads to an intra-abdominal reaction, an internal hernia should be kept as a differential diagnosis. The delay in diagnosis and surgical intervention is associated with potentially disastrous complications.
... When the bowel is incarcerated too tightly to reduce, and the bowel is still viable, it may be necessary to enlarge the defect as well. In the case of necrosed bowel, resection of the concerned bowel segment with anastomosis is done [3,18]. Concluding the operative procedure, the entire mesentery is searched to detect other mesenteric defects to prevent future herniation [19]. ...
Background
Transmesenteric hernia is a subtype of internal abdominal hernia (IAH) and is a rare cause of small bowel obstruction in the adult. Difficulty in reaching a definitive diagnosis due to non-specific clinical and imaging findings often cause life-threatening bowel ischemia.
Case report
We report a case of a 37-year-old male who presented with clinical and imaging features of small bowel obstruction. He underwent an emergency laparotomy where the diagnosis of transmesenteric hernia causing closed-loop obstruction was made. The non-viable portion of the intestine was resected, anastomosis of the ileum along with the closure of the mesenteric defect was performed.
Discussion
IAH is the protrusion of abdominal viscera, most commonly small bowel loops through a peritoneal or mesenteric defect into the abdominal or pelvic cavity. Considered common in children, it is rare in adults and is most common after abdominal surgeries like Roux-en-Y gastric bypass surgery. Clinical features and imaging findings are non-specific causing delay in the diagnosis.
Conclusion
A high index of suspicion is required while assessing the patient with symptoms suggestive of acute bowel obstruction as the preoperative diagnosis of a transmesenteric hernia is challenging.
... The operative management for a transmesenteric hernia consists of timely laparotomy, reduction of the hernia, resection of bowel if necrotized and closure of the defect [5]. When the bowel is incarcerated too tightly to reduce as was observed in our patient's case, it may be necessary to enlarge the defect to avoid bowel injuries [9]. ...
Transmesenteric hernia is a rare cause of small bowel strangulation in adults and, to our knowledge, no one has reported the existence of two mesenteric defects in an adult. Our patient was a 73-year-old Japanese woman who presented to our emergency department complaining of abdominal pain and nausea. Computed tomography with contrast enhancement revealed a closed loop obstruction in the pelvis, suggesting small bowel strangulation due to an internal hernia. The emergency exploratory laparotomy indicated a small bowel strangulation caused by a transmesenteric hernia. With the examination across whole parts of the mesentery, we identified another small defect. Both defects were closed by suture intraoperatively, and the patient’s postoperative course was satisfactory. Searching for whole parts of the mesentery after the reduction of a hernia can help prevent the recurrence of internal hernias.
... 3 Otros defectos como las hernias mesentéricas son causa de obstrucción intestinal, pueden ser congénitas o adquiridas, las primeras son más comunes en la población pediátrica. 6 La agenesia del mesenterio dorsal y atresia yeyunal es una entidad conocida que hace parte del síndrome de Apple Peel small bowel (APSB) 7 asociada con agenesia de partes del intestino delgado. La primera descripción de agenesia aislada de mesenterio fue hecha en 1960 por Blandy quien reportó un caso de obstrucción intestinal generada por una hernia en el mesenterio. ...
La agenesia del mesenterio es una anomalía rara y por esta razón no se piensa cuando se tiene una historia de dolor crónico abdominal. Se han reportado casos de agenesia de mesenterio, partes de intestino y arteria mesentérica superior, junto con atresia intestinal. Este caso corresponde a un paciente pediátrico con agenesia total de mesenterio asociada con vólvulo del íleon y malrotación intestinal. El dolor abdominal crónico en la población pediátrica es una de las consultas más frecuentes en urgencias. Las causas son múltiples pero es importante establecer el diagnóstico oportuno para evitar desenlaces fatales
... In older literature, congenital internal hernias were the most frequent types of all IHs, but recent studies report the increase of the acquired types [10,11]. The surgical treatment results for congenital types were also much better than the results for acquired types [12][13][14][15]. Delayed laparotomy time (>3 days after the onset of the symptoms) and the presence of a comorbidity were related to high morbidity [16]. ...
Aim: An internal hernia is a very rare cause of acute small bowel obstruction and perforation which may be difficult to diagnose. We aimed to provide a retrospective
study for management and evaluated patients who underwent surgery for perforation due to intestinal internal herniation in our department. Material and Method: From January 2012 to April 2017, seven patients underwent surgery for a perforation due to intestinal internal herniation at our clinic. We retrospectively reviewed the patients’ records, imaging modalities, and operative findings. Results: There were two women and five men with a mean age of 52.50± 11.22 years. All patients were admitted to our emergency surgery unit with the complaints of acute abdominal pain, distension, and fever. All patients were
urgently operated. The mean hospital stay was 5.50 ± 1.37 days. In the postoperative period, two patients had wound infection, and postoperative mortality was not observed. Discussion: Perforation due to an internal hernia occur because of the delayed diagnosis of the internal hernia. Unfortunately, they have bad outcomes. They usually rapidly progress to bowel ischemia once strangulated and have no definitive predictors. At surgery, complete closure of the potential defects that may predispose to an internal hernia is essential for prevention. Especially in patients who had previous abdominal surgery, internal hernia should be kept in mind to prevent delay in diagnosis.
... In older literature, congenital internal hernias were the most frequent types of all IHs, but recent studies report the increase of the acquired types [10,11]. The surgical treatment results for congenital types were also much better than the results for acquired types [12][13][14][15]. Delayed laparotomy time (>3 days after the onset of the symptoms) and the presence of a comorbidity were related to high morbidity [16]. ...
Primary internal hernia is a rare entity of acute intestinal obstruction. Delay in diagnosis and surgical intervention can cause ischaemia or gangrene of the small bowel and result in high morbidity and mortality. A 14-year-old boy presented to the emergency department with acute intestinal obstruction. On exploration, 3-4cm mesenteric defect was noted in the ileal region. Strangulated loops of the small bowel had gone through the mesenteric defect in a complicated way. Primary anastomosis was done after resection of the gangrenous small bowel.
Key words: Primary internal hernia, Acute intestinal obstruction.
Introduction:
Transmesenteric herniae are a rare cause of bowel ischaemia in adults with few reported cases in published literature.
Presentation of case:
We report a rare case of a 26-year-old female with spontaneous transmesenteric hernia of jejunum and proximal ileum due to a congenital mesenteric defect resulting in bowel gangrene, presenting initially with no haemodynamic or biochemical abnormalities. The hernia was reduced, small bowel resected and primary side to side anastomosis performed, following which the patient made a good recovery and was discharged 5 days later.
Discussion:
The insidious onset of transmesenteric herniae and lack of specific radiological or laboratory investigations reaffirms the importance of surgeons maintaining a high index of suspicion for this critical surgical emergency.
Conclusion:
Close monitoring of the patient's general condition in cases of non-specific abdominal pain is essential to identify the rare deteriorating patient for early surgical intervention and optimal outcome.
Introduction:
Internal intestinal hernia has been defined as a bulging of the intestines through a normal or an abnormal peritoneal or mesenteric opening.(1) Internal hernias are a rare cause of small-bowel obstruction, with a reported incidence of 0.2-0.9%.(2)
Presentation of case:
In this report, the patient presented with multiple episodes of intestinal obstruction. High index of suspicion aided the appropriate management of this case. An abdominal CT revealed signs of small bowel obstruction. With negative signs and symptoms indicating adhesions, malignancy or inflammatory causes, mesenteric defect was suspected. When the patient underwent laparotomy, multiple mesenteric defects were found.
Discussion:
In the adult population, acquired mesenteric defects are more common than congenital defects. They can be caused by bowel surgery or abdominal trauma.(11) Patients with a history of blunt abdominal trauma may present with late complication caused by a missed diagnosis of an associated injury, such as bowel mesenteric injuries. In this case, the author describes a patient who developed multiple attacks of small bowel obstruction. He had no previous history of similar symptoms but did give a history of recent abdominal trauma managed conservatively. An abdominal CT was performed, and it showed signs of a mesenteric defect. In such a case, early operative intervention is essential to decrease morbidity and increase survival. (16)
Conclusion:
The diagnosis of post traumatic mesenteric injuries can be missed in conservatively managed trauma cases. For this reason, the decision of non-operative approach should be made following the exclusion of associated injuries.
Internal hernias are a rare cause of small bowel obstruction and are estimated to account for 1% to 5% of cases. Herniation through a defect in the sigmoid mesocolon constitutes 6% of all internal hernias.
In this case report we describe a rare case of a fit and healthy 60-year-old man, with no previous history of abdominal surgery, who presented with signs and symptoms of small bowel obstruction as a result of an incarcerated transmesosigmoid hernia. The hernia was reduced and the incarcerated loop of small bowel was found to be viable. The patient made a good recovery and was discharged home on the fourth post-operative day.
Internal hernias can cause considerable morbidity and mortality, so prompt diagnosis is paramount. Transmesosigmoid hernias are most common in the paediatric population; however, our patient was 60 years old. This report highlights the importance of considering an internal hernia as a cause of small bowel obstruction in individuals of all age groups and especially in those without a previous history of abdominal surgery.
Congenital transmesenteric internal hernia is a rare condition presenting as recurrent pain abdomen or acute intestinal obstruction. Preoperative diagnosis of internal hernia is very rare. Early intervention and surgical correction goes a long way in preventing high morbidity and mortality associated with cases of internal hernia. We report a case of congenital transmesenteric intra-abdominal hernia presented as acute abdomen with timely surgical intervention in the form of emergency laparotomy with untwisting and reduction of small bowel herniated through large congenital terminal ileal mesenteric defect and repair of mesenteric defect.
Transmesenteric hernias are internal hernias caused by a congenital defect in the mesentery. They are rare causes of intestinal obstruction, but most commonly affect the small bowel. We report an unexpected death of an infant with a bowel obstruction caused by a congenital mesenteric defect, which was undiagnosed despite visits to three different hospitals. Mesenteric defects are usually 2-3 cm in diameter. At autopsy, we found an oval, 14 × 7 cm congenital defect in the ileal mesentery through which the small bowel had herniated. Diagnosis of such defects remains difficult, even with currently available imaging techniques. Diagnosis is particularly difficult in infants who usually have nonspecific symptoms. Therefore, it is important that sudden unexpected deaths in children undergo full forensic evaluation to establish the precise cause of death. It is also important for forensic physicians to inform clinicians of the risk of such diseases, particularly in emergency situations.
Transmesenteric hernias are extremely rare. A strangulated hernia through a mesenteric opening is a rare operative finding. Preoperative diagnosis still is difficult in spite of the imaging techniques currently available. The authors describe two cases of paediatric patients presenting with bowel obstruction resulting from a congenital mesenteric hernia. The first patient had a 3-cm wide congenital defect in the ileal mesentery through which the sigmoid colon had herniated. The second patient is a newborn infant who presented with symptoms and radiographic evidence of neonatal occlusion. At surgical exploration, a long segment of the small bowel had herniated in a defect in the ileal mesentery. A brief review of epidemiology and anatomy of transmesenteric hernias is included, along with a discussion of the difficulties in diagnosis and treatment of this condition.
Internal hernias are neglected, life threatening and generally mismanaged surgical pathologies. They may be either acquired or congenital. The mortality and morbidity rates differ between the types and unfortunately reports investigating them are very rare, with limited number of patients, and mostly case reports. In this one of the largest series of the literature, we aimed to evaluate the resemblances and the differences between these two types.
From January 2001 to April 2008, 25 patients who underwent surgery for an internal hernia were evaluated. Patients were divided into two groups; group I consisted of patients with acquired internal hernia, and group II with congenital internal hernia. The patients' records, imaging modalities, and operative findings were recorded and analyzed statistically.
Group I consisted of 16 patients whilst group II consisted of nine patients. There were no significant differences between the groups with regard to gender, patients' complaints, clinical and laboratory findings, imaging modalities, types of surgical procedures, and laparotomy time. Group I was significantly older, had significantly longer length of hospital stay (13.6+/-2.3 days versus 7.2+/-1.4 days) and had significantly higher postoperative mortality rate (43.8% in group I and 22.2% in group II, p<0.01).
Acquired IH is becoming the most prevalent type of IH. They usually have rapid progression to bowel ischemia, so they have bad outcome. High index of suspicion is mandatory since the main factors that may influence the prognosis of affected patients are early diagnosis and therapy.
Gastrointestinal causes of sudden and/or unexpected death in the young are uncommon and only rarely involve congenital anomalies of the mesentery. Two cases are reported of unexpected deaths following herniation of intestine through congenital mesenteric defects to illustrate the forensic issues that may arise. Case 1 involves a 2.5-year-old girl who collapsed on arrival to hospital following 18 hours of fever and apparently mildly nonspecific symptoms. Resuscitation was unsuccessful, and at autopsy a segment of gangrenous small intestine was found that had herniated through a congenital mesenteric defect. Case 2 involves a 23-year-old woman with a past history of severe mental and physical disabilities who was found dead in her bed. She had a recent history of mild diarrhea and vomiting, but had not appeared particularly ill. At autopsy the peritoneal cavity was filled with a very dilated and obstructed colon as a result of herniation of a segment of sigmoid colon through a distal small intestinal mesenteric defect. These cases demonstrate that symptoms and signs of intestinal ischemia may not be clearly manifested in early childhood and that developmental delay may also result in older individuals presenting in a nonspecific manner. Although rare, congenital mesenteric abnormalities with compromise of the intestinal vasculature remain a possibility to be considered at autopsy in all cases of unexpected death, despite the lack of a clear history of significant gastrointestinal disturbance. Death may relate to ischemic compromise of either the herniated portion of intestine (as in case 1) or to the stretched intestine bordering the hernial orifice (as in case 2).
Congenital mesenteric defects and unexpected death-a rare finding at autopsy. Pediatric Developmental Pathology
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Malit M. Burionarappa S. Congenital mesenteric defects and unexpected death-a rare finding
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