Presentation
81 year old female with a past history of Crohn's disease and end ileostomy, presents with abdominal pain and distension.
Patient Data
Previous colectomy. The oversewn rectosigmoid is pulled upwards and to the right. The suture site is unremarkable. Submucosal fat within this remnant large bowel is in keeping with chronic inflammation secondary to the known history of IBD.
Left iliac fossa end ileostomy, and associated parastomal hernia. At the neck of the hernia, three adjacent small bowel transition points are identified on a single axial slice. There is a closed loop obstruction of a small loop of small bowel that lies within the parastomal hernial sac. This loop of bowel is mildly distended and thick walled. The associated mesentery within the hernial sac demonstrates venous congestion, and there is a small pocket of free fluid within the hernial sac. There is a second closed loop obstruction of small bowel that lies within the peritoneal cavity, the point of obstruction also being at the level of the hernial neck. The small bowel involved is dilated up to 57mm. Upstream of these closed loop obstructions, there is a small left inguinal hernia that contains a loop of unremarkable small bowel. No pneumatosis intestinalis identified. The proximal jejunum is collapsed.
No focal liver lesion. Indentation of segment 6 by a prominent diaphragmatic slip is noted. The gallbladder, portal vein, spleen, adrenal glands and kidneys have an unremarkable appearance other than a 15 mm interpolar renal cyst on the left. Other than the aforementioned free fluid within the parastomal hernial sac, no free intraperitoneal fluid identified.
There is an irregular cystic lesion in the tail of pancreas with associated focus of internal calcification that measures 24mm. Within the uncinate process, there is a 29 mm cystic lesion. There is also a smaller rounded cystic lesion in the inferior portion of the head of pancreas that measures approximately 9 mm. The main pancreatic duct at the level of the pancreatic head measures 5 mm and is stable. The common bile duct is not dilated.
Old left superior and inferior pubic rami fractures. Multiple vertebral compression fractures appear chronic.
Conclusion:
Left iliac fossa parastomal hernia, with two separate closed loop small bowel obstructions, one within the parastomal hernial sac, the other within the peritoneal cavity.
Uncomplicated left inguinal hernia.
Multiple cystic lesions within the tail and uncinate process of the pancreas.
Case Discussion
Closed loop obstruction occurs when two separate points along the small bowel are obstructed at a common point. There is a high risk of bowel strangulation and infarction.
In this case, there are two separate closed loop obstructions that share a common obstructing point at the hernial orifice of the left iliac fossa parastomal hernia.
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