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Review of Internal Hernias: Radiographic and Clinical Findings

¹ All authors: Department of Radiology, Duke University Medical Center, Box 3808, Durham, NC 27710.

View larger version (88K): [in a new window]   Fig. 1 —Diagrammatic illustration shows various types of internal hernias: A = paraduodenal, B = foramen of Winslow, C = intersigmoid, D = pericecal, E = transmesenteric, and F = retroanastomotic.

View larger version (91K): [in a new window]   Fig. 2 —Graphic illustration of a left paraduodenal hernia depicts loop of small bowel prolapsing (curved arrow) through Landzert's fossa, located behind inferior mesenteric vein and ascending left colic artery (straight arrow). Herniated bowel loops are therefore located lateral to fourth portion of duodenum.

View larger version (135K): [in a new window]   Fig. 3A —Left paraduodenal hernias shown on upper gastrointestinal series, and barium enema in one patient and lateral view of upper gastrointestinal series from different patients. 55-year-old man with gastrointestinal bleeding. Anteroposterior projection of oral contrast small-bowel study shows cluster of small-bowel loops in left upper quadrant, lateral to fourth portion of duodenum (arrow).

View larger version (126K): [in a new window]   Fig. 3B —Left paraduodenal hernias shown on upper gastrointestinal series, and barium enema in one patient and lateral view of upper gastrointestinal series from different patients. Barium enema study (anteroposterior projection) from same patient as in A depicts inferior displacement of distal transverse colon and splenic flexure (arrow) caused by mass in left upper quadrant that was later revealed to be left paraduodenal hernia.

View larger version (105K): [in a new window]   Fig. 3C —Left paraduodenal hernias shown on upper gastrointestinal series, and barium enema in one patient and lateral view of upper gastrointestinal series from different patients. Lateral radiograph from upper gastrointestinal series in 35-year-old woman with abdominal pain shows small-bowel loops (arrow) causing mass effect and indentation on posterior aspect of stomach (S), displacing it anteriorly.

View larger version (144K): [in a new window]   Fig. 4A —CT scans from six patients with left paraduodenal hernia. Axial contrast-enhanced CT scan in 11-year-old boy shows small-bowel loops (arrows) between stomach (S) and pancreas (P).

View larger version (149K): [in a new window]   Fig. 4B —CT scans from six patients with left paraduodenal hernia. Axial contrast-enhanced CT scan in 28-year-old man shows small-bowel loops (white arrow) behind pancreas (P) itself. Black arrow indicates stomach.

View larger version (145K): [in a new window]   Fig. 4C —CT scans from six patients with left paraduodenal hernia. Axial contrast-enhanced CT scan in 36-year-old man shows small-bowel loops (arrows) displaying inferior mesenteric vein (arrowhead) to left.

View larger version (169K): [in a new window]   Fig. 4D —CT scans from six patients with left paraduodenal hernia. Coronal reconstruction of contrast-enhanced CT data set in 28-year-old man shows small-bowel loops between transverse colon (T) and left adrenal gland (arrow).

View larger version (119K): [in a new window]   Fig. 4E —CT scans from six patients with left paraduodenal hernia. Unenhanced axial CT scan in 35-year-old man shows evidence of small-bowel obstruction of herniated contents as multiple loops of dilated small bowel (arrow) with fluid-fluid levels noted.

View larger version (134K): [in a new window]   Fig. 4F —CT scans from six patients with left paraduodenal hernia. Axial contrast-enhanced CT scan in 23-year-old man shows multiple engorged and prominent vessels (arrow) in herniated sac caused by vascular congestion and obstruction.

View larger version (110K): [in a new window]   Fig. 5 —Graphic illustration of right paraduodenal hernia shows loop of small bowel prolapsing (curved arrow) through Waldeyer's fossa, behind superior mesenteric artery (straight arrow) and inferior to third portion of duodenum (asterisk).

View larger version (144K): [in a new window]   Fig. 6A —23-year-old man with abdominal pain. Anteroposterior projection from oral contrast small-bowel study reveals cluster of small-bowel loops (asterisk) posterior and lateral to second and third portions of duodenum (arrow).

View larger version (132K): [in a new window]   Fig. 6B —23-year-old man with abdominal pain. Contrast-enhanced CT scan shows abnormal loop of small bowel (arrow) in right upper quadrant and reveals right paraduodenal hernia.

View larger version (76K): [in a new window]   Fig. 7 —Diagrammatic illustration of pericecal hernia shows loop of ileum prolapsing (arrow) through cecal mesenteric defect, behind and lateral to cecum, into right paracolic gutter.

View larger version (110K): [in a new window]   Fig. 8A —60-year-old man with right lower quadrant pain. Single anteroposterior radiograph from barium enema study shows retrograde filling of herniated distal ileum (arrows) as loops of ileum pass posterior to cecum (C) through defect of ileocecal mesentery to reach right paracolic fossa. (Reprinted with permission from [1])

View larger version (99K): [in a new window]   Fig. 8B —60-year-old man with right lower quadrant pain. Contrast-enhanced axial CT scan shows loops of small bowel (arrow) posterior and lateral to cecum (asterisk) in right paracolic gutter, producing small-bowel obstruction. (Courtesy of Ghahremani GG, San Diego, CA)

View larger version (75K): [in a new window]   Fig. 9 —Graphic illustration of foramen of Winslow hernia shows bowel about to prolapse (arrow) into lesser sac, behind hepatoduodenal ligament, the free edge of the lesser omentum.

View larger version (142K): [in a new window]   Fig. 10A —54-year-old woman with abdominal pain. Anteroposterior radiograph from upper gastrointestinal series shows abnormal cluster of small-bowel loops located in lesser sac, representing foramen of Winslow internal hernia.

View larger version (138K): [in a new window]   Fig. 10B —54-year-old woman with abdominal pain. Oblique lateral view from same gastrointestinal series shows abnormal cluster of small-bowel loops posterior to stomach (asterisk), indenting (arrows) and displacing stomach anteriorly.

View larger version (157K): [in a new window]   Fig. 10C —54-year-old woman with abdominal pain. Contrast-enhanced axial CT scan shows cluster of small-bowel loops (arrow) located in lesser sac, posterior to stomach (arrowhead).

View larger version (134K): [in a new window]   Fig. 11A —70-year-old man with severe epigastric pain. Anteroposterior projection of radiograph shows large collection of gas in left upper quadrant (arrows).

View larger version (140K): [in a new window]   Fig. 11B —70-year-old man with severe epigastric pain. Barium enema (anteroposterior view) shows large, air-filled structure in upper abdomen (arrows), originally thought to represent a distended stomach but surgically confirmed to be cecum involved in foramen of Winslow hernia.

View larger version (87K): [in a new window]   Fig. 12 —Diagrammatic illustration of intersigmoid hernia shows bowel protruding (arrow) through defect in sigmoid mesocolon to lie posterolateral to sigmoid colon itself.

View larger version (146K): [in a new window]   Fig. 13 —85-year-old man with abdominal pain. Axial CT scan of sigmoid-related hernia (type 2, transmesosigmoid) reveals small-bowel loops (arrow) protruding through defect in sigmoid mesocolon, which usually occurs between left psoas muscle (arrowhead) and sigmoid colon (S), to lie posterior and lateral to sigmoid colon itself.

View larger version (79K): [in a new window]   Fig. 14 —Diagrammatic illustration shows retrocolic Roux-en-Y procedure, with loop of small bowel about to herniate through transverse mesocolon (arrow) at surgically created defect, in keeping with transmesocolic internal hernia.

View larger version (127K): [in a new window]   Fig. 15 —40-year-old woman with nausea and vomiting. Contrast-enhanced axial CT scan of transmesenteric internal hernia 19 months after Roux-en-Y procedure shows dilated loops of duodenum (large black asterisk) and jejunum (white asterisk) in expected location of Roux loop. Note that Roux limb (arrowhead) is compressed. Straight arrows, curved arrow, and small black asterisk represent colon. (Reprinted with permission from [19])

View larger version (114K): [in a new window]   Fig. 16 —36-year-old man with sudden onset of abdominal pain. Radiograph (anteroposterior projection) shows distended air-filled gastric remnant, which is normal finding in recently postoperative patient. However, in this patient several months after surgery, this finding is most worrisome for obstruction at distal anastomosis of Roux-en-Y loop.

View larger version (98K): [in a new window]   Fig. 17A —CT scans in two different patients with transmesenteric internal hernias. Contrast-enhanced axial CT scan of 84-year-old woman showing transmesenteric internal hernia after Roux-en-Y procedure shows dilated, fluid-filled loops of small bowel lateral to ascending colon (arrow) and displacing omental fat because loops of bowel lie directly beneath anterior abdominal wall (arrowheads).

View larger version (113K): [in a new window]   Fig. 17B —CT scans in two different patients with transmesenteric internal hernias. Axial contrast-enhanced CT scan at level of transverse mesocolon in a 40-year-old woman shows dilated loop of jejunum directly abutting anterior abdominal wall (white asterisk). In addition, note compression of pancreaticobiliary limb (straight arrows), whereas Roux limb (small arrowhead) is barely visible. Large arrowhead, black asterisk, and curved arrow indicate colon. (Reprinted with permission from [19])

View larger version (67K): [in a new window]   Fig. 18 —Diagrammatic illustration shows retrocolic Roux-en-Y gastric bypass procedure. Arrow indicates loop of small bowel protruding posterior to enteroenterostomy, in keeping with a retroanastomotic internal hernia.

View larger version (91K): [in a new window]   Fig. 19A —CT scans from two different patients showing retroanastomatic hernias. Contrast-enhanced axial CT scan of retroanastomotic hernia in 35-year-old woman shows loops of dilated fluid-filled small bowel (arrow) in left upper quadrant.

View larger version (110K): [in a new window]   Fig. 19B —CT scans from two different patients showing retroanastomatic hernias. Axial CT scan in 58-year-old woman 2 months after Roux-en-Y gastric bypass shows herniated loop posterior to jejunojejunostomy site (straight arrow) and dilated proximal Roux limb (large arrowheads). Note decompressed distal ileal loops (small arrowheads) and colon (curved arrows). (Reprinted with permission from [19])

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