Abdominal Imaging

ª Springer Science+Business Media, LLC 2006 Published online: 1 September 2006

Abdom Imaging (2007) 32:81–83 DOI: 10.1007/s00261-006-9083-2

Pericecal hernia of the inferior ileocecal recess: CT findings Chun-Yu Fu,1 Wei-Chou Chang,2 Huai-En Lu,1 Chung-Jen Su,1 Kuang-Huan Tan1 1 2

Department of Surgery, Songshan Armed Forced General Hospital, Taipei, Taiwan, Republic of China Department of Radiology, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan, Republic of China

Abstract Internal abdominal herniations are rare. A 34-year-old healthy man was seen in the emergency room because of severe lower abdominal pain and episodic vomiting. Pericecal internal herniation of the inferior ileocecal recess was suspected by abdominal CT study and confirmed by exploratory laparotomy. Finally, the herniated ileal loops were reduced, and the redundant peritoneum was resected. In the present case, CT demonstrates the precise anatomic diagnosis and shows acute complications that should be recommended preoperatively. Urgent surgical intervention is necessary to prevent strangulation, which is responsible for high mortality. Early diagnosis and treatment had a good outcome. Key words: Pericecal hernia—Internal abdominal hernia—Computed tomography—Surgery—Abdomen

Internal abdominal herniation is defined as the protrusion of an abdominal organ through a normal or abnormal mesenteric, epiploic, or peritoneal aperture. It is a rare condition either acquired through trauma, surgical procedure, or due to congenital anomalies such as bands, peritoneal or mesenteric weaknesses or defects, or abnormal bowel rotation. About 4.1% of all intestinal obstructions are caused by internal abdominal herniations [1]. Here, we present a case in which intestinal obstruction resulted from an unusual anatomic location of inferior ileocecal recess.

Case report A 34-year-old Chinese man in previously good health was seen in the emergency room because of increasing Correspondence to: Huai-En Lu, Department of Surgery, Songshan Armed Forced General Hospital, No. 131, Jian Kang Road, Songshan 105, Taipei, Taiwan, Republic of China; email: chougo2002@yahoo. com.tw

Fig. 1. Scout film shows localized gaseous distention of the small bowel in the right upper quadrant.

lower abdominal pain and episodic vomiting over the course of 1 day. On physical examination, diffuse tenderness and guarding were demonstrated. Laboratory tests were normal, except for a white blood cell count of 14,241 mm)3 with a predominance of neutrophils (89%). Scout film showed localized gas distention of small bowel in the right upper quadrant of the abdomen (Fig. 1). Contrast-enhanced CT images revealed trapped clustering of small-bowel loops located in the lateral aspect of the right paracolic gutter (Fig. 2A), and the reformed coronal CT images showed abnormal disposition of mesenteric vessels (Fig. 2B), confirming pericecal internal herniation of the inferior ileocecal recess. The patient underwent exploratory laparotomy urgently. The ascending colon and cecum were displaced

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C.-Y. Fu et al.: Pericecal hernia of the inferior ileocecal recess

Fig. 2. A Contrast-enhanced axial CT scan at the renal pelvis level shows clustering of ileal loops (asterisk) with abnormal course of mesenteric vessels (arrow) through the pericecal fossa. The ascending colon (arrowhead) is displaced medially. B Reformed coronal CT scan shows abnormal disposition of mesenteric vessels (arrow). Pericecal hernia was confirmed at surgery.

medially by a herniated protrusion located lateral to the cecum. A segment of ileum about 100 cm in length was herniated into the retro-peritoneal cavity via the defect of inferior ileocecal recess (Fig. 3). Trapped ileal loops without strangulation were identified. The herniated ileal loops were reduced and the redundant peritoneum was resected. The right colon and cecum were returned to their lateral anatomic position following repair of the hernia orifice. The patient had a good postoperative recovery and was well at the 1-year follow-up.

Discussion Internal abdominal herniations are classified by location: paraduodenal hernias (50.5%), hernias through the foramen of Winslow (6.0%), transmesenteric hernias (8.0%), pericecal hernias (10.5%), intersigmoid hernias (4%), and paravesical hernias (<4%) [2]. In human embryology, rotation of the midgut, followed by migration of the ileocecal portion of the intestine to the right iliac fossa, occurs in the 5th fetal month. Variant recesses and fossae may be formed during fusion and resorption of the peritoneal surfaces following arrival of the cecum in the right iliac fossa. The abdominal recesses may become hernia orifices, and four types of peritoneal recesses are found in the pericecal region that includes superior ileocecal recess, inferior ileocecal recess, retrocecal recess, and paracolic sulci [3]. Our case appeared to be congenital pericecal herniation of a segment of ileum trapped in the peritoneal pocket of the inferior ileocecal recess. Clinical symptoms of all internal abdominal herniations are identical and nonspecific that consist of mild abdominal discomfort alternating with episodes of intense periumbilical pain and nausea, acute bowel obstruction with strangulation, or as chronic intermittent partial obstruction. Therefore, without imaging studies, it is difficult to make a definite diagnosis between internal abdominal herniations and other mechanisms causing intestinal obstruction.

Fig. 3. Illustration demonstrates a pericecal hernia and hernial protrusion located lateral to the cecum and displacing the ascending colon and cecum medially.

A variety of diagnostic radiological procedures are available, and CT has been known to show more precise abdominal anatomy than plain films and contrast studies, either with barium or water-soluble contrast medium. CT also can accurately demonstrate the site and cause of intestinal obstruction and show the pathologic processes of the bowel wall, mesentery, and peritoneal cavity [4, 5]. Therefore, it is highly recommended to be performed if the patient is suspected of intestinal obstruction when the clinical and initial radiographic findings remain indeterminate. Specific CT signs and findings of internal abdominal herniations have been reported, notably by

C.-Y. Fu et al.: Pericecal hernia of the inferior ileocecal recess

the reformatted multiplanar coronal images [6, 7]. Thus, pericecal hernia was diagnosed with certainty in our patient when CT demonstrated clustering of dilated or edematous small bowel loops located adjacent or lateral to the cecum [8]. Urgent surgical intervention is necessary because delay in treatment can cause small bowel damage, ischemia, and necrosis responsible for high morbidity and mortality. In conclusion, CT facilitates the diagnosis of internal abdominal herniations and CT scans in patients with suspected intestinal obstruction may be necessary for accurate evaluation before operation. In this case, pericecal hernia was demonstrated by CT and confirmed by exploratory laparotomy. The patient had a good outcome because of prompt diagnosis and treatment.

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References 1. Sufian S, Matsumoto T (1975) Intestinal obstruction. Am J Surg 130:9–14 2. Ghahremani GG (1994) Abdominal and pelvic hernias. In: Gore RM, Levine MS, (eds). Textbook of gastrointestinal radiology. Philadelphia: Saunders 3. Rivkind AI, Shiloni E, Muggia-Sullam M, et al. (1986) Paracecal hernia: a cause of intestinal obstruction. Dis Colon Rectum 29:752– 754 4. Furukawa A, Yamasaki M, Furuichi K, et al. (2001) Helical CT in the diagnosis of small bowel obstruction. Radiographics 21:341–355 5. Boudialf M, Soyer P, Terem C, et al. (2001) CT evaluation of small bowel obstruction. Radiographics 21:613–624 6. Mathieu D, Luciani A (2004) GERMAD Group. Internal abdominal herniations. AJR 183:397–404 7. Zarvan NP, Lee FT Jr, Yandow DR, et al. (1995) Abdominal hernias: CT findings. AJR 164:1391–1395 8. Lu HC, Wang J, Tsang YM, et al. (2002) Case report: pericecal hernia: a report of two cases and survey of the literature. Clin Radiol 57:855–858