A 77‐year‐old white male with no past medical or surgical history presented with 36 hours of progressive, nonradiating, abdominal pain. His pain started in Ihe epigastric region and moved to the right lower quadrant. He had nausea and 1 episode of nonbilious vomiting earlier. There were no aggravating or relieving factors for his pain. He denied melena, hematochezia, hemalemesis, and fever. Vital signs were normal. Physical exam revealed significant RLO tenderness but no guarding or rigidity. Bowel sounds were present. Rectal exam showed formed, guaiac negative stool. CBC was unremarkable with WBC 7200/mm3. BMP, LFT, lipase, and lactic acid were all normal. CT abdomen and pelvis showed no SBO or acute appendicitis. When no improvement was noticed after 8 hours, surgical evaluation was requested. The patient underwent laparoscopy which revealed a strangulated pericecal internal hernia with 30 cm of ischemic small bowel. Small bowel resection with primary anastomosis was performed. The postoperative course was unremarkable
Common causes of RLQ pain are appendicitis, diverticulitis, ischemic colitis, mesenteric ischemia, IBD, infectious colitis, and colonic neoplasm. Internal hernias are an uncommon cause of abdominal pain, but if untreated they are fatal. Common types of internal hernias are paraduodenal, transmesenteric, transomental, pericecal, intersigmoid, and obturator. Bariatric surgery, intraabdominal inflammatory conditions are risk factors. The presentation ranges from nonspecific Gl complaints to acute SBO. Characteristic CT findings are SBO, saclike mass of dilated bowel loops, mesenteric vascular pedicle abnormalities, and signs of bowel ischemia; but CT may be normal. When initial labs and imaging studies are unable to identify a cause of abdominal pain, internal hernias must be considered in differential diagnoses. In such patients, early surgical consultation must be sought because surgical correction is lifesaving.
We are reporting this case to raise awareness about internal hernias. These are uncommon but present with common nonspecific Gl symptoms, making its diagnosis difficult. If untreated they can be fatal.
M. Cratty, none; R. Khehra, none.