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Para duodenal Hernias- A pictorial essay

L DAYANANDA, KP SREEKUMAR, S MOORTHY, NK PRABHU Ind J Radiol Imag 2006 16:4:469-471 Key words : Paraduodenal Hernia, Intestinal obstruction Introduction Intestinal obstruction is a common clinical condition that is usually suspected on the basis of clinical signs and patient history. For many decades, evaluation was based on findings at conventional radiography, with a sensitivity of 69% and a specificity of 57% (1). Several studies have demonstrated the value of CT in confirming the diagnosis and revealing the cause of small bowel obstruction, with a sensitivity of 94%-100% and an accuracy of 90%-95% (1,2). Internal hernias are rare cause for intestinal obstruction. Para duodenal hernias constitute approximately 53% of all internal hernias (3,4). These rare hernias have unique radiological finding which allow definitive diagnosis to be made. In this article we will review relevant anatomy of the peritoneal cavity and characteristic CT appearance of para duodenal hernias. Discussion: Para duodenal hernias are the most common type of internal abdominal hernias accounting for half of reported cases (3,4). They are basically congenital in origin representing entrapment of small intestine beneath the mesentery of colon probably occurring due to abnormal embryologic rotation of midgut and variation in peritoneal fixation and vascular folds. Para duodenal hernias occur more commonly on the left side (3,4). Clinical features The clinical manifestation of para duodenal hernias can be quite variable varying from mild abdominal cramps or occasional vomiting to acute intestinal obstruction. Postprandial pain with postural variation is a characteristic symptom. Inferior mesenteric vein compression in left para duodenal hernias may lead to hemorrhoids (3).

Fig 1 a: Anatomy of left para duodenal fossa: 1) Fossa of Landzert. 2) Colon. 3) 3rd part of duodenum .4) 4th part of duodenum. 5) Inferior mesenteric vein.

Fig 1 b: Anatomy of left para duodenal fossa: 1) 3rd part of duodenum. 2) Left Para duodenal hernia. 3) Fossa of Landzert. 4) Inferior mesenteric vein. 5) Tributaries of Inferior mesenteric vein. From the Dept of Radiology, Amrita Institute of Medical Sciences, Amrita Lane, Elamakkara P.O, Kochi-682026 Request for Reprints: Dr.Dayananda.L , Assistant professor . Department of radiology. Amrita Lane, Elamakkara P.O, Cochin 682 026, Kerala, India. Received 26 July 2006; Accepted 20 October 2006

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Anatomic considerations Left para duodenal hernias (Fig 1a and 1b) The left Para duodenal fossa of Landzert present in 2% of autopsy cases is situated to the left of ascending or fourth part of the duodenum and is caused by the raising up of a peritoneal fold by the inferior mesenteric vein as it runs along the lateral side of fossa and then above it (3). Small intestine may herniate through the orifice posteriorly and downward to the left, lateral to the ascending limb of duodenum extending into descending mesocolon and left part of the transverse mesocolon. The free edge of hernia thus contains the inferior mesenteric vein and ascending left colic artery (3). Right para duodenal hernias (Fig 2) The right para duodenal fossa of Waldeyer is present in 1% of autopsy cases (3). It is situated within the first part of mesentery of jejunum, immediately behind the superior mesenteric artery and inferior to transverse duodenum (3). The fossa orifice looks to the left, its blind extremity to right and downward, directly in front of posterior parietal peritoneum. Right para duodenal hernias represent an entrapment of small bowel behind the ascending mesocolon and right half of transverse mesocolon. The superior mesenteric artery and the right colic vein are in the free edge of the hernia.

IJRI, 16:4, November 2006 cluster of dilated small bowel loops to the left of fourth part of duodenum extending into the descending mesocolon (4,5,6). The mesenteric vessels supplying the affected loop can appear engorged. The Inferior mesenteric vein and the ascending left colic artery can be seen above the herniated loop along the anterior aspect. The transverse colon lies anterior to the hernial sac. Normal vascular relationship of Superior mesenteric artery and vein is usually maintained.

Fig 3: Left para duodenal hernia: Axial CT section showing left Para duodenal hernia (horizontal arrow), Inferior mesenteric vein (vertical arrow) and engorged mesenteric vessels supplying affected loop (arrow head).

Fig 4: Right of para duodenal hernia: Axial CT sections showing right Para duodenal hernia (horizontal arrow), superior mesenteric artery (vertical arrow) and colon (curved arrow) Fig 2: Anatomy of right para duodenal fossa: 1) Transverse colon. 2) Descending colon 3) 3rd part of duodenum. 4) Jejunum 5) mesentery of jejunum 6) Right Para duodenal hernia.

Right para duodenal hernia (Fig 4) The characteristic CT finding is an abnormal cluster of small bowel loops in the ascending mesocolon. The Superior mesenteric artery and the right colic vein are located in the anteromedial border of the encapsulated small bowel loops (4,5,6). Bowing of the jejunal branches

Computed tomography of para duodenal hernias Left para duodenal hernia (Fig 3): The characteristic CT appearance consists of an abnormal

471 IJRI, 16:4, November 2006 of Superior mesenteric artery and vein to right and posterior is a corroborative CT finding (Fig 5). The hepatic flexure of colon is seen anterior to the hernial sac. The normal relationship between Superior mesenteric artery and vein is maintained. When the herniation is superimposed on malrotation the normal relationship between Superior mesenteric artery and vein is lost. References:
1. Maglinte DD, Gage SN, Harmon BH, et al. Obstruction of the small intestine: accuracy and role of CT in diagnosis. Radiology 1993; 188:61-64. Frager D, Madwid SW, Baer JW, et al. CT of small-bowel obstruction: value in establishing the diagnosis and determining the degree and cause. AJR Am J Roentgenol 1994; 162:37-41.. Mayers MA. Internal abdominal hernias. In: Mayers MA, ed. Dynamic radiology of the abdomen. 5th ed. New York, NY: Springer-Verlag, 2000; 711-748 Nobuyuki T, Takehiko G, Yoshimitsu O, Shuichi, CT of Internal Hernias. RadioGraphics 2005; 25:997-1015. Okino Y, Kiyosue H, Mori H, et al. Root of the small-bowel mesentery: correlative anatomy and CT features of pathologic conditions. RadioGraphics 2001; 21:14751490. Olazabal A, Guasch I, Casas D. CT diagnosis of nonobstructive left paraduodenal hernia. Clin Radiol 1992; 46:288-289.

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Fig 5: Right para duodenal hernia: Axial CT sections showing upper jejunal arteries are redirected medially and posteriorly just beyond their origin from superior mesenteric artery (horizontal arrows).

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