Clinical Imaging 39 (2015) 152–154
Contents lists available at ScienceDirect
Clinical Imaging journal homepage: http://www.clinicalimaging.org
Retro-ureteral internal hernia after transperitoneal ureter reimplantation: an unusual cause of small bowel obstruction Arnaud Flores a, Amel Azizi a, Ouaji Idelcadi b, Anne-Sarah Tholozan b, Nicolas Badet a, Eric Delabrousse a,⁎ a b
Department of Radiology, University Hospital of Besançon, 3 boulevard Alexander Fleming, 25030 Besançon, France Department of Surgery, Hospital of Montbéliard, 2 rue du Dr Flamand, 25200 Montbéliard, France
a r t i c l e
i n f o
Article history: Received 14 March 2014 Received in revised form 13 June 2014 Accepted 2 July 2014
a b s t r a c t Report of a case of surgically confirmed closed-loop small bowel obstruction due to internal hernia following transperitoneal ureter reimplantation. Multidetector computed tomography (CT) demonstrated the presence and the cause of this unusual postsurgical internal hernia. The CT findings are presented herein. © 2015 Elsevier Inc. All rights reserved.
Keywords: Internal hernia Ureter reimplantation Multidetector computed tomography Small bowel obstruction
1. Introduction Internal hernia is a rare cause of small bowel obstruction (SBO), with a reported incidence of 0.5–4% [1,2]. Internal hernias are defined as a protrusion of a bowel loop through a normal or abnormal peritoneal or mesenteric aperture within the confines of the peritoneal cavity. The orifice can either be congenital, including both normal apertures (such as the foramen of Winslow) and abnormal apertures (arising from anomalies of internal rotation and peritoneal attachment) or acquired, for instance, by traumatic, postinflammatory, or postsurgical defect [3,4]. This report is concerned with a case of closed-loop SBO due to internal hernia following transperitoneal ureter reimplantation and describes computed tomography (CT) features we think are diagnostic of this unusual condition. 2. Case presentation A 34-year-old woman with a background history of endometriosis with three pelvic laparoscopic surgeries presented herself to our institution's emergency department with a diffuse abdominal pain that had started 6 h earlier. Furthermore, she complained of nausea and vomiting. Her medical records showed no history of any previous episode of this kind, and her last surgery, performed 2 years before, consisted of a resection of an endometriosic lesion that invaded the distal right ureter and transperitoneal reimplantation of the ureter after realizing a psoic bladder. ⁎ Corresponding author. Service de Radiologie viscérale, CHRU Besançon, Hôpital Jean Minjoz, 3, Boulevard Fleming, 25030 Besançon, France. Tel.: +33-3-81-66-93-80. E-mail address: [email protected] (E. Delabrousse). http://dx.doi.org/10.1016/j.clinimag.2014.07.001 0899-7071/© 2015 Elsevier Inc. All rights reserved.
Physical examination showed normal bowel sounds at auscultation, and her abdomen was found to be depressible. No fever and no evidence of peritoneal irritation were noted. On admission, biological findings revealed a white blood cell count of 17.5 G/l (with 80% of neutrophil cells) and a subnormal C-reactive protein level (7 mmol/l). Contrast-enhanced multidetector computed tomography (MDCT) (Brillance 16, Philips Healthcare, The Netherlands) of the abdomen and the pelvis was performed because mechanical SBO was highly suspected. Oral contrast media was given to the patient 5 min before the start of the scanning, and scanning began 80 s after starting an intravenous injection of 90 ml of iodine-containing contrast media (Iomeron 300, Bracco, Italy) delivered at a flow rate of 3 ml/s using a power injector (OptiVantage Dual-Head Injector, Guerbet, France). The CT parameters were as follows: slice thickness of 2.0 mm and 1.0 mm reconstruction intervals. Images were reconstructed with a soft-tissue algorithm. All images were transferred to an independent workstation for interpretation using manual cine-paging and reformations. The CT scans revealed a cluster of strangulated small bowel loops located within the right flank and a right ureter with an intraperitoneal location, stretched from the right kidney to the psoic bladder and bridging anteriorly the mesentery of the involved small bowel. No vanished bowel wall, pneumatosis intestinalis, or free air was diagnosed. Coronal and sagittal reformations were allowed to better demonstrate some relevant CT findings (Fig. 1), which were consistent with a strangulated closed-loop SBO secondary to a retro-ureteral internal hernia (Fig. 2). Subsequently, the patient was taken to the operating room for urgent laparotomy. SBO due to a right retro-ureteral internal hernia was confirmed at surgery (Fig. 3). A bowel resection was necessary because the herniated bowel loops were infarcted, and direct restoration of intestinal continuity
A. Flores et al. / Clinical Imaging 39 (2015) 152–154
153
Fig. 1. Contrast-enhanced MDCT. (a) Coronal reformation CT scan shows a cluster of small bowel loops (arrowheads) and two bowel beak signs located at the neck of the internal hernia; (b) Sagittal reformation CT scan shows a closed-loop SBO and the mesentery of the herniated bowel loops (star) crossing posteriorly the stretched right ureter (arrowheads).
with termino-lateral anastomosis and parietalisation of the ureter to the pelvic wall was also performed. The patient's postoperative course was unremarkable. 3. Discussion Internal hernias are divided into two different types: congenital internal hernias and acquired internal hernias. Acquired
Fig. 2. Schematic representation of the retro-ureteral internal hernia after transperitoneal ureter reimplantation.
hernias are mostly due to abdominal trauma, intraperitoneal infection, and abdominal or pelvic surgery. One of the most frequent internal hernias due to pelvic surgery is a broad ligament hernia; though very rarely, pelvic surgery requiring transperitoneal ureter reimplantation may also be the cause for internal hernia. To the best of our knowledge, only four cases of retro-ureteral internal hernias have been previously reported in the surgical literature [5–8]: three of these were due to ureter reimplantation following gynecologic surgery [5–7], and one was caused by antireflux plasty performed in childhood [8]. None of these hernias were preoperatively diagnosed. Obviously, clinical diagnosis of internal hernia remains extremely difficult because of its nonspecific clinical presentation and its rare occurrence [9]. MDCT is currently regarded as the best imaging modality for the examination of the acute abdomen, especially in cases of bowel obstruction. Furthermore, MDCT has been reported to be very useful in the diagnosis of internal hernias. Indeed, it allows the diagnosis of closed-loop SBO, as first described by Balthazar et al. [10], and obviously the use of multiplanar reformations helps the radiologist identify precisely the neck of the hernia and the anatomical structure or aperture responsible, especially after surgery with altered anatomy. In our case, even if unfortunately no pielographic phase was performed during CT examination, the intraperitoneal ureter was diagnosed as the very cause of the internal hernia on CT scans. MDCT features included: (a) a cluster of strangulated small bowel loops located within the right flank, (b) two adjacent bowel beak signs corresponding to the two transition zones of the closed-loop obstruction, (c) the intraperitoneal location of the right ureter which was stretched from the right kidney to the psoic bladder, and (e) the mesentery of the herniated small bowel crossing posterior to the right ureter. We think that this combination of MDCT findings associated with a history of transperitoneal ureter reimplantation is diagnostic for retro-ureteral internal hernia. Preoperative recognition of such an unusual type of hernia by CT is crucial since the stretched intraperitoneal ureter may mimic an adhesive band at surgery, especially in patients with a history of recurrent pelvic surgeries. Moreover, preoperative diagnosis made at MDCT may lead to an appropriate treatment early on. Open or laparoscopic surgery is then mandatory and would include reduction of the herniated bowel loops,
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A. Flores et al. / Clinical Imaging 39 (2015) 152–154
Acknowledgments We thank Pierre Prigent for the schematic representation of the hernia.
References
Fig. 3. Intraoperative photograph showing an aperture (star) posterior to the right ureter (arrowhead).
loop resection if required and prevention of the recurrence by closure of the retro-ureteral aperture.
[1] Takeyama N, Goyan T, Ohgiya Y, Satoh S, Hashizume T, Hataya K, Kushiro H, Nakanishi M, Munechika H. CT of internal hernias. Radiographics 2005;25:997–1015. [2] Ghahremani GG. Abdominal and pelvic hernias. In: Gore RM, Levine MS, editors. Textbook of gastrointestinal radiology. 2nd ed. Philadelphia: Saunders; 2000. p. 1993–2009. [3] Martin LC, Merkle EM, Thompson WM. Review of internal hernias: radiographic and clinical findings. AJR Am J Roentgenol 2006;186:703–17. [4] Hongo N, Mori H, Matsumoto S, Okino Y, Takaji R, Komatsu E. Internal hernias after abdominal surgeries: MDCT features. Abdom Imaging 2011;36:349–62. [5] Takagi Y, Mizui S, Mori S, Fukada D, Saji S, Kanematsu M. Ureteric band obstruction of the small intestine after radical gynecologic surgery. J Clin Gastroenterol 2002;34:10. [6] Hussain IF, Magee TR, Faber RG, Malone PR. Transperitoneal ureter following ureteric reimplantation: a rare cause of small bowel obstruction and infarction. Br J Urol 1997;80:156. [7] Hocken DB, Kapff PD. Ureteric band obstruction of the small bowel following radical hysterectomy case report. Br J Obstet Gynaecol 1998;95:533. [8] Hay DJ. Acute small bowel obstruction 20 years after reimplantation of the ureter. Br J Urol 1981;53:83. [9] Ghiassi S, Nguyen S Q, Divino C M, Byrn J C, Schlager A. Internal hernias: clinical findings, management, and outcomes in 49 nonbariatric cases. J Gastrointest Surg 2007;11:291–5. [10] Balthazar EJ, Birnbaum DA, Megibow AJ, Gordon RB, Whelan CA, Hulnick DH. Closed-loop and strangulating intestinal obstruction: CT signs. Radiology 1992; 185:769–75.
Contents lists available at ScienceDirect
Clinical Imaging journal homepage: http://www.clinicalimaging.org
Retro-ureteral internal hernia after transperitoneal ureter reimplantation: an unusual cause of small bowel obstruction Arnaud Flores a, Amel Azizi a, Ouaji Idelcadi b, Anne-Sarah Tholozan b, Nicolas Badet a, Eric Delabrousse a,⁎ a b
Department of Radiology, University Hospital of Besançon, 3 boulevard Alexander Fleming, 25030 Besançon, France Department of Surgery, Hospital of Montbéliard, 2 rue du Dr Flamand, 25200 Montbéliard, France
a r t i c l e
i n f o
Article history: Received 14 March 2014 Received in revised form 13 June 2014 Accepted 2 July 2014
a b s t r a c t Report of a case of surgically confirmed closed-loop small bowel obstruction due to internal hernia following transperitoneal ureter reimplantation. Multidetector computed tomography (CT) demonstrated the presence and the cause of this unusual postsurgical internal hernia. The CT findings are presented herein. © 2015 Elsevier Inc. All rights reserved.
Keywords: Internal hernia Ureter reimplantation Multidetector computed tomography Small bowel obstruction
1. Introduction Internal hernia is a rare cause of small bowel obstruction (SBO), with a reported incidence of 0.5–4% [1,2]. Internal hernias are defined as a protrusion of a bowel loop through a normal or abnormal peritoneal or mesenteric aperture within the confines of the peritoneal cavity. The orifice can either be congenital, including both normal apertures (such as the foramen of Winslow) and abnormal apertures (arising from anomalies of internal rotation and peritoneal attachment) or acquired, for instance, by traumatic, postinflammatory, or postsurgical defect [3,4]. This report is concerned with a case of closed-loop SBO due to internal hernia following transperitoneal ureter reimplantation and describes computed tomography (CT) features we think are diagnostic of this unusual condition. 2. Case presentation A 34-year-old woman with a background history of endometriosis with three pelvic laparoscopic surgeries presented herself to our institution's emergency department with a diffuse abdominal pain that had started 6 h earlier. Furthermore, she complained of nausea and vomiting. Her medical records showed no history of any previous episode of this kind, and her last surgery, performed 2 years before, consisted of a resection of an endometriosic lesion that invaded the distal right ureter and transperitoneal reimplantation of the ureter after realizing a psoic bladder. ⁎ Corresponding author. Service de Radiologie viscérale, CHRU Besançon, Hôpital Jean Minjoz, 3, Boulevard Fleming, 25030 Besançon, France. Tel.: +33-3-81-66-93-80. E-mail address: [email protected] (E. Delabrousse). http://dx.doi.org/10.1016/j.clinimag.2014.07.001 0899-7071/© 2015 Elsevier Inc. All rights reserved.
Physical examination showed normal bowel sounds at auscultation, and her abdomen was found to be depressible. No fever and no evidence of peritoneal irritation were noted. On admission, biological findings revealed a white blood cell count of 17.5 G/l (with 80% of neutrophil cells) and a subnormal C-reactive protein level (7 mmol/l). Contrast-enhanced multidetector computed tomography (MDCT) (Brillance 16, Philips Healthcare, The Netherlands) of the abdomen and the pelvis was performed because mechanical SBO was highly suspected. Oral contrast media was given to the patient 5 min before the start of the scanning, and scanning began 80 s after starting an intravenous injection of 90 ml of iodine-containing contrast media (Iomeron 300, Bracco, Italy) delivered at a flow rate of 3 ml/s using a power injector (OptiVantage Dual-Head Injector, Guerbet, France). The CT parameters were as follows: slice thickness of 2.0 mm and 1.0 mm reconstruction intervals. Images were reconstructed with a soft-tissue algorithm. All images were transferred to an independent workstation for interpretation using manual cine-paging and reformations. The CT scans revealed a cluster of strangulated small bowel loops located within the right flank and a right ureter with an intraperitoneal location, stretched from the right kidney to the psoic bladder and bridging anteriorly the mesentery of the involved small bowel. No vanished bowel wall, pneumatosis intestinalis, or free air was diagnosed. Coronal and sagittal reformations were allowed to better demonstrate some relevant CT findings (Fig. 1), which were consistent with a strangulated closed-loop SBO secondary to a retro-ureteral internal hernia (Fig. 2). Subsequently, the patient was taken to the operating room for urgent laparotomy. SBO due to a right retro-ureteral internal hernia was confirmed at surgery (Fig. 3). A bowel resection was necessary because the herniated bowel loops were infarcted, and direct restoration of intestinal continuity
A. Flores et al. / Clinical Imaging 39 (2015) 152–154
153
Fig. 1. Contrast-enhanced MDCT. (a) Coronal reformation CT scan shows a cluster of small bowel loops (arrowheads) and two bowel beak signs located at the neck of the internal hernia; (b) Sagittal reformation CT scan shows a closed-loop SBO and the mesentery of the herniated bowel loops (star) crossing posteriorly the stretched right ureter (arrowheads).
with termino-lateral anastomosis and parietalisation of the ureter to the pelvic wall was also performed. The patient's postoperative course was unremarkable. 3. Discussion Internal hernias are divided into two different types: congenital internal hernias and acquired internal hernias. Acquired
Fig. 2. Schematic representation of the retro-ureteral internal hernia after transperitoneal ureter reimplantation.
hernias are mostly due to abdominal trauma, intraperitoneal infection, and abdominal or pelvic surgery. One of the most frequent internal hernias due to pelvic surgery is a broad ligament hernia; though very rarely, pelvic surgery requiring transperitoneal ureter reimplantation may also be the cause for internal hernia. To the best of our knowledge, only four cases of retro-ureteral internal hernias have been previously reported in the surgical literature [5–8]: three of these were due to ureter reimplantation following gynecologic surgery [5–7], and one was caused by antireflux plasty performed in childhood [8]. None of these hernias were preoperatively diagnosed. Obviously, clinical diagnosis of internal hernia remains extremely difficult because of its nonspecific clinical presentation and its rare occurrence [9]. MDCT is currently regarded as the best imaging modality for the examination of the acute abdomen, especially in cases of bowel obstruction. Furthermore, MDCT has been reported to be very useful in the diagnosis of internal hernias. Indeed, it allows the diagnosis of closed-loop SBO, as first described by Balthazar et al. [10], and obviously the use of multiplanar reformations helps the radiologist identify precisely the neck of the hernia and the anatomical structure or aperture responsible, especially after surgery with altered anatomy. In our case, even if unfortunately no pielographic phase was performed during CT examination, the intraperitoneal ureter was diagnosed as the very cause of the internal hernia on CT scans. MDCT features included: (a) a cluster of strangulated small bowel loops located within the right flank, (b) two adjacent bowel beak signs corresponding to the two transition zones of the closed-loop obstruction, (c) the intraperitoneal location of the right ureter which was stretched from the right kidney to the psoic bladder, and (e) the mesentery of the herniated small bowel crossing posterior to the right ureter. We think that this combination of MDCT findings associated with a history of transperitoneal ureter reimplantation is diagnostic for retro-ureteral internal hernia. Preoperative recognition of such an unusual type of hernia by CT is crucial since the stretched intraperitoneal ureter may mimic an adhesive band at surgery, especially in patients with a history of recurrent pelvic surgeries. Moreover, preoperative diagnosis made at MDCT may lead to an appropriate treatment early on. Open or laparoscopic surgery is then mandatory and would include reduction of the herniated bowel loops,
154
A. Flores et al. / Clinical Imaging 39 (2015) 152–154
Acknowledgments We thank Pierre Prigent for the schematic representation of the hernia.
References
Fig. 3. Intraoperative photograph showing an aperture (star) posterior to the right ureter (arrowhead).
loop resection if required and prevention of the recurrence by closure of the retro-ureteral aperture.
[1] Takeyama N, Goyan T, Ohgiya Y, Satoh S, Hashizume T, Hataya K, Kushiro H, Nakanishi M, Munechika H. CT of internal hernias. Radiographics 2005;25:997–1015. [2] Ghahremani GG. Abdominal and pelvic hernias. In: Gore RM, Levine MS, editors. Textbook of gastrointestinal radiology. 2nd ed. Philadelphia: Saunders; 2000. p. 1993–2009. [3] Martin LC, Merkle EM, Thompson WM. Review of internal hernias: radiographic and clinical findings. AJR Am J Roentgenol 2006;186:703–17. [4] Hongo N, Mori H, Matsumoto S, Okino Y, Takaji R, Komatsu E. Internal hernias after abdominal surgeries: MDCT features. Abdom Imaging 2011;36:349–62. [5] Takagi Y, Mizui S, Mori S, Fukada D, Saji S, Kanematsu M. Ureteric band obstruction of the small intestine after radical gynecologic surgery. J Clin Gastroenterol 2002;34:10. [6] Hussain IF, Magee TR, Faber RG, Malone PR. Transperitoneal ureter following ureteric reimplantation: a rare cause of small bowel obstruction and infarction. Br J Urol 1997;80:156. [7] Hocken DB, Kapff PD. Ureteric band obstruction of the small bowel following radical hysterectomy case report. Br J Obstet Gynaecol 1998;95:533. [8] Hay DJ. Acute small bowel obstruction 20 years after reimplantation of the ureter. Br J Urol 1981;53:83. [9] Ghiassi S, Nguyen S Q, Divino C M, Byrn J C, Schlager A. Internal hernias: clinical findings, management, and outcomes in 49 nonbariatric cases. J Gastrointest Surg 2007;11:291–5. [10] Balthazar EJ, Birnbaum DA, Megibow AJ, Gordon RB, Whelan CA, Hulnick DH. Closed-loop and strangulating intestinal obstruction: CT signs. Radiology 1992; 185:769–75.
