An Interesting case of Retrocaecal internal herniation causing Small bowel Obstruction

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1 Accepted Manuscript An Interesting case of Retrocaecal internal herniation causing Small bowel Obstruction A.O. Rae, Core trainee,year 2 General Surgery, A. Kalyanaraman, SpR in General Surgery, A.E. Ward, FY1 General Surgery, A.B. Harikrishnan, Consultant in Colorectal Surgery PII: DOI: Reference: AMSU 106 S (15) /j.amsu To appear in: Annals of Medicine and Surgery Received Date: 26 January 2015 Revised Date: 12 June 2015 Accepted Date: 24 June 2015 Please cite this article as: Rae A, Kalyanaraman A, Ward A, Harikrishnan A, An Interesting case of Retrocaecal internal herniation causing Small bowel Obstruction, Annals of Medicine and Surgery (2015), doi: /j.amsu This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.

2 An Interesting case of Retrocaecal internal herniation causing Small bowel Obstruction Rae AO*, Kalyanaraman A, Ward AE, Harikrishnan AB Rae, Akin Onigbinde* - Core trainee, year 2, General Surgery, Sheffield Teaching Hospitals, Sheffield S5 7AU Address; 78 Hunter hill road, Sheffield S11 8UE Mobile: akin.rae@nhs.net Kalyanaraman A SpR in General Surgery, Sheffield Teaching Hospitals, Sheffield S5 7AU aarti.kalyanaraman@sth.nhs.uk Ward AE FY1, General Surgery, Sheffield Teaching Hospitals, Sheffield S5 7AU aeward@doctors.org.uk Harikrishnan AB Consultant in Colorectal Surgery, Sheffield Teaching Hospitals, Sheffield S5 7AU athur.harikrishnan@sth.nhs.uk CONSENT Written informed consent was obtained from the patient for publication of this case report and accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal on request.

3 An Interesting case of retrocaecal internal herniation causing Small bowel Obstruction CONSENT Written informed consent was obtained from the patient for publication of this case report and accompanying images. A copy of the written consent is available for review by the Editor-in- Chief of this journal on request.

4 ABSTRACT Herein, we report a case of an elderly woman with multiple co-morbidities who presented with clinical findings indicative of small bowel obstruction (SBO), which was confirmed on a CT scan. She underwent a laparotomy, which demonstrated herniation of small bowel into a retrocaecal position. Gangrenous small bowel was resected and primary anastomosis performed. After a brief period on the High Dependency Unit (HDU), she returned to the ward and was discharged back to the community. Key words: small bowel obstruction, retrocaecal hernia, internal hernia, small bowel resection. BACKGROUND An internal hernia is a protrusion of bowel through a normal or abnormal orifice in the peritoneum or mesentery. They have been reported to have an overall incidence of less than 1%, however they also constitute up to 5.8% of all small-bowel obstructions. If strangulated and left untreated, internal hernias have an overall mortality greater than 50% 1,2. Although rare, as clinicians we should be aware of the significant mortality associated with an internal hernia and when suspected, urgent surgery is recommended to give best patient outcome.

5 CASE PRESENTATION An 85 year old woman with significant co-morbidities, who had previously had a appendicectomy presented to the Surgical Assessment Centre with a one day history of sudden onset, severe abdominal pain, vomiting and obstipation. On examination, she was apyrexial, haemodynamically stable and clinically tender in the epigastrium/ periumbilical region. Small bowel obstruction (possibly adhesional) was the working diagnosis. Differential diagnosis included bowel malignancy or other extraluminal lesions causing obstruction. Her admission blood results show moderate leukocytosis. Due to her significant co-morbidities, an initial decision was made to treat her conservatively but by the next morning, she had become tachycardic with rising inflammatory markers and local signs of peritonism in the right iliac fossa (RIF). She was resuscitated with intravenous fluids and received further intravenous analgesia and antibiotics. CT scan reported small bowel obstruction. A decision was then made to proceed to laparotomy (Fig 1 + 2). Intraoperatively, there was free fluid in the abdomen with dilated proximal small bowel from the duodenal jejunal flexure to a point mid small bowel, where there was herniation into a space behind the caecum and ascending colon causing mechanical small bowel obstruction. As this loop of bowel was gangrenous, a decision was made to

6 perform small bowel resection and primary anastomosis with closure of the retrocaecal space. Postoperatively, she was admitted to the high dependency unit (HDU) for observation for 24 hours and subsequently discharged just over a week later with no post op complications. She was followed up at 6 weeks, and was found to be making good progress and was subsequently discharged back to the care of her General Practitioner. Histology of the resected bowel revealed ischaemic changes only. DISCUSSIONS An internal hernia is an abnormal protrusion of the viscera through the peritoneum or mesentery and into a compartment in the abdominal cavity. It usually presents as an acute SBO developing through normal or abnormal orifices 3. The usual orifices through which herniation occurs are usually pre-existing anatomic structures such as foramens and fossa but they may also occur through pathological defects in the mesentery and visceral peritoneum which may be present congenitally, caused by surgery, trauma or through an inflammatory process 4. Meyer has classified boundaries of internal hernias into six, including, paracecal sulci, caecal fossa, caecal recess, superior ileocaecal recess and retrocaecal recess 5. The broad classification of internal hernias consist of paraduodenal (53%), pericaecal (13%), foramen of Winslow (8%), transmesenteric and transmesocolic (8%), intersigmoid (6%) and retroanastomotic (5%) 5.

7 There are many cases of internal hernias that have been reported in the literature 6,7 but few cases of retrocaecal hernias 8,9,10,11,12. CT scanning is useful for diagnosing small bowel obstruction but the detection of internal herniation by CT is often difficult 13. The initial CT report in our patient did not detect the presence of a retrocaecal hernia. In retrospect, on discussing the CT scan post operatively with a radiologist, it was felt that the CT scan did suggest the presence of an internal hernia; however the cause could not be determined on the CT (Fig 1 + 2). These CT findings suggesting internal hernia include mesenteric vessel abnormalities such as engorgement, crowding and twisting 13. Dilatation of small bowel loops with a transition zone which is adjacent to the caecum or an oedematous small intestine which is found lateral to the caecum allows a paracaecal hernia to be diagnosed with a high certainty 13. In the case described by Bharatam et al, a CT scan of a young man presenting with a transmesenteric hernia detected this hernia although it did not show SBO 6. Mehra & Pujahari s description of two cases of paraduodenal hernias did not utilise CT in their diagnostic work up, instead opting for AXR, followed by laparotomy in the first case and a barium swallow followed by laparotomy in the second 7. Lindsey s and Nottle s diagnosis of a retrocaecal hernia in an elderly lady was made at laparoscopy, with no pre-operative CT scan 8. An interesting case of paracaecal hernia presenting as acute appendicitis also revealed the difficulties which can arise in the diagnoses of the types of hernias. In this case, a CT scan was performed but only reported an area of abnormality in the RIF. A case of retrocaecal hernia reported by Singh and Yedalwar did not use CT scan in it s operative workup and that described by Cerrahi did, although the findings in the report did not prove a pericaecal hernia.

8 In our patient, it may be that that the retrocaecal space through which the small bowel had herniated through and strangulated was created during her previous appendicectomy or it may have been congenital. Our patient was managed appropriately with a quick decision to operate being made based on a clinical suspicion of possible strangulation rather than blind reliance on the CT findings. Intraoperative confirmation soon followed. Post operatively, despite her co-morbidities, she was discharged ten days later with no complications. This case highlights the importance of maintaining a high index of suspicion in patients presenting with peritonism. It also highlights that imaging should not be over-relied and may not always give the diagnosis of internal hernias pre-operatively. Laparotomy is the general procedure performed for the treatment of internal hernias, however laparoscopyfor the repair of these hernias have become more popular 14. LEARNING POINTS/TAKE HOME MESSAGES 1. CT scanning can play a role for the diagnosis of small bowel obstruction but may not pick up internal hernia. 2. Internal hernias remain an uncommon cause of small bowel obstruction but an important one given the high mortality associated. 3. Early surgical decision-making should be on the basis of clinical suspicion of small bowel ischaemia. A laparotomy should be performed in this situation. 4. If a retrocaecal defect is found, this should be closed this to prevent further internal herniation.

9 REFERENCES 1. Ghahremani GG. Abdominal and pelvic hernias. In: Gore RM, Levine MS, eds. Textbook of gastrointestinal radiology, 2nd ed. Philadelphia, PA: Saunders, 2000: Newsom BD, Kukora JS. Congenital and acquired internal hernias: unusual causes of small bowel obstruction. Am J Surg 1986; 152: GhahremaniGG. Internal abdominal hernias. Surg Clin North Am1984; 64: NewsomBD, Kukora JS. Congenital and acquired internal hernias: unusual causes of small bowel obstruction. Am J Surg1986; 152: Meyer A, Nowotony K, Poeschl M. Internal hernias of the ileocaecal region. Ergeb Chir Orthop. 1963; 44: Bharatam KK, Kaliyappa C, Reddy RR. Right sided transmesenteric hernia: A rare cause of acute abdmomen in adults. Int J Surg Case Rep. 2014; 5(12): Mehra R, Pujahari AK. Right paraduodenal hernia: report of two cases and review of literature. Gastroenterol Rep (Oxf) Nov Lindsey I, Nottle PD. Laparoscopic management of small bowel obstruction caused by retrocaecal hernia. Surg laparosc Endoc Aug;7(4): Paron L, Peirano M, Sacco D, Cardino L. Intestinal occlusion caused by internal hernia of the retrocaecal recess. Description of a case. Minerva Chir Jul;48(13-14):801-2

10 10. Dhillon A, Farid SG, Dixon S, Evans J. Right salpingo-ovarian and distal ileal entrapment within a paracaecal hernia presenting as acute appendicitis. Int J Surg case rep. 2013;4(12): Singh LM, Yedalwar V. Retrocaecal hernia: A rare cause of small bowel obstruction. Journ Evol Med & Dent Sci (20): Cerrahi G. A rare cause of mechanical intestinal obstruction: Primary internal pericaecal hernia CausaPedia 4; 3: Martin LC, Merkle EM, Thompson WM. Review of Internal hernias: Radiographic and clinical findings. AJR. 2006; 186: Kabashima A, N Ueda, Y Yonemura, K Mashino, K Fujii. Laparoscopic surgery for the diagnosis and treatment of a paracecal hernia repair: Report of a case. Surg Today. 2010; 40: Legend Fig 1 + 2: CT scan images demonstrating the features suggestive of small bowel herniation into the retrocaecal space. IMAGING CT abdomen (Images attached) Within the abdomen, there are dilated loops of distal ileum with an apparent transition point just proximal to the terminal ileum. Appearances are suggestive of small bowel obstruction.

11 Internal herniation through retrocaecal space Fig 1 + 2: CT scan images demonstrating the features suggestive of small bowel herniation into the retrocaecal space. Internal herniation?through congenital or post-operative retrocaecal space

12 Highlights 1. Internal hernias remain an uncommon cause of small bowel obstruction but an important one given the high mortality associated. We present an interesting case of an elderly lady presenting with CT confirmed small bowel resection. 2. Surgical decision-making should be on the basis of clinical suspicion of small bowel ischaemia and a laparotomy should be performed as is standard practice. Our patient had a laparotomy where a gangrenous small bowel internal herniation into a retrocaecal space was found. This was resected and she subsequently was discharged home. 3. If a defect is found, an attempt should be made to close this to prevent further internal herniation through the same defect in future.