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Case Report |
1 Department of Radiology, Toyonaka Municipal Hospital, 4-14-1 Shibahara-Cho,
Toyonaka, Osaka 560-0055, Japan.
2 Present address: Department of Radiology, Sakai City Hospital, 1-1-1
Minamiyasui-cho Sakai, Osaka 590-0064, Japan.
3 Department of Surgery, Toyonaka Municipal Hospital, Osaka 560-0055,
Japan.
Received February 7, 2002;
accepted after revision April 23, 2002.
Address correspondence to Y. Inoue.
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We report the CT findings of a rare case of internal hernia through a peritoneal defect of the pouch of Douglas. To our knowledge, no previous CT findings of this type of internal hernia have been reported.
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An abdominal CT scan was obtained. Most small-bowel loops were dilated and filled with fluid (Fig. 1A). A cluster of nondilated loops of small bowel was seen between the uterine cervix and the rectum (Fig. 1B). The nondilated terminal ileum was seen in the right lower quadrant. A small amount of gas was observed in the large bowel, implying an incomplete obstruction of the ileum.
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A nasoenteric tube was inserted. Enteroclysis with water-soluble iodinated contrast medium administered through the tube with the tip of the tube at mid jejunum showed an abrupt narrowing of the ileum in the pelvic bottom and a cluster of small-bowel loops anterior to the rectum (Fig. 1C). Delayed images showed contrast material in the large bowel.
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The patient's abdominal distention continued, and serial abdominal radiographs showed persistent dilated bowel loops. The patient underwent laparotomy on her fifth day in the hospital. A peritoneal defect was found between the uterine cervix and the rectum. A segment of ileum between 130 and 160 cm from the ileocecal valve herniated into the peritoneal defect. The musculature of the pelvic floor was intact. The herniated bowel loops were reduced manually and were viable. The peritoneal defect was sutured. Postoperative recovery was uneventful.
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We have found only one report of internal hernia through the pouch of Douglas in the English literature [6]. In that patient, a segment of the small bowel herniated through a defect of the pouch of Douglas that was believed to be congenital; the segment was incarcerated in the defect. In our patient, the peritoneal defect might have been associated with the previous hysterectomy.
The most common region of internal hernia is paraduodenal, accounting for 53% of the reported cases. The less common regions include the foramen of Winslow, the pericecal region, the mesenterium, the mesocolon, or the omentum. The pelvis is one of the least common sites for an internal hernia; pelvic hernias constitute 7% of the cases [2]. Acquired internal hernias constitute 43-54% of the internal hernias and arise from herniation of a bowel segment through a surgically created mesenteric or peritoneal defect or an opening by anastomosis [1,2,3].
CT signs of an internal hernia include evidence of small-bowel obstruction; a cluster of small-bowel loops; stretched, displaced, or engorged mesenteric vessels; and displacement of other bowel segments. A herniated segment of bowel loops that is completely obstructed may become dilated with retained fluid. In the case of strangulation, ischemic bowel loops may show edematous thickening of the wall [7].
In our patient, CT disclosed a cluster of collapsed small-bowel loops in the peritoneal defect between the rectum and the uterine cervix. The proximal segments of the small-bowel loops were prominently dilated with an accumulation of fluid. The herniated loops were collapsed, signifying incomplete obstruction of the efferent loops, which was confirmed by enteroclysis.
As in our patient, a bowel hernia through the broad ligament may present similar CT findings involving a cluster of bowel loops in the pouch of Douglas. Ureteral obstruction may accompany that condition [8].
In conclusion, with the finding of a cluster of bowel loops in the pouch of Douglas, an internal hernia should be included in the diagnosis in the appropriate clinical setting.
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