Case Report

Congenital Mesenteric Defect with Internal Herniation:

A Case Report
Chih-An Chen1

Lung-Huang Lin1,2,* Te-Fang Chen3 Shin-Hung Huang4

A 3-month-old female patient suffering from poor peripheral circulation and paleness for 1 day
was diagnosed with a congenital mesenteric defect with internal herniation. A plain abdominal xray revealed dilatation of bowel loops with ileus, while a lateral abdominal x-ray demonstrated the
presence of several air-fluid levels. Abdominal ultrasonography revealed dilated, fluid-filled bowel
loops. Abdominal CT revealed diffuse dilatation of the small-bowel loops. These findings led to the
diagnosis of a congenital mesenteric defect with internal herniation. Exploratory laparotomy with
segmental resection of the small intestine and an enterostomy was performed. Follow-up involved
weekly visits to our outpatient department. The patient's daily activities and feeding status had
returned close to normal after 1 month. No further signs of ileus were noted thereafter.
( FJJM 2010; 8 (2): 123-128 )
Key words: ileus, internal hernia, mesenteric defect, Pediatric

INTRODUCTION
Internal hernias are the underlying cause of
acute or intermittent intestinal obstruction in
approximately 0.5%~5.8% of cases[1]. Most internal
hernias occur postoperatively as a consequence of
incomplete closure of surgically created mesenteric
defects. Without a heightened awareness and
understanding of these hernias, they are often
misdiagnosed, leading to subsequent morbidity and
be mortality[1].
Internal herniation caused by defects in the
gastrointestinal mesentery is extremely rare[2].
Mesenteric hernias occur when an intestinal loop
protrudes through an abnormal opening in the

mesentery of the small bowel or colon. The most

common location for this type of hernia is the
mesentery of the small intestine, most often near
the ileocolic junction. Other locations include the
appendix, sigmoid colon, and Meckel's diverticulum.
Patients may present with a variety of symptoms
including abdominal pain, distension, nausea,
vomiting, and constipation[3-5]. Most internal
mesenteric hernias develop postoperatively, while
a preoperative diagnosis of a congenital mesenteric
defect causing internal herniation is extremely rare.
This condition is often misdiagnosed[6].
The clinical presentation is generally nonspecific,
and clinical and radiologic diagnoses can sometimes
be challenging[7]. Obstructing congenital internal

Department of Pediatrics, Cathay General Hospital, Taipei, Taiwan1 College of Medicine, Fu-Jen Catholic University, Hsinchuang, Taipei,
Taiwan2 Department of Surgery, Cathay General Hospital, Taipei, Taiwan3 Department of Pathology, Cathay General Hospital, Taipei,
Taiwan4
Submitted March, 23, 2010; final version accepted June, 05, 2010.
*Corresponding author: E-mail: B001089081@tmu.edu.tw

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Chih-An Chen

Lung-Huang Lin

Te-Fang Chen

Shin-Hung Huang

hernias are usually published as case reports or

small case series, while larger series include both
congenital and acquired internal hernias[8]. In our
case, initial symptoms were a poor appetite and
abdominal distension, but she became severely illlooking within 10 h. After the operation, necrosis
of the intestines was revealed. A misdiagnosis of
internal hernias can result in delayed exploration,
which in turn may lead to small-bowel necrosis
and subsequent mortality. Because definitive clinical
identification is difficult, the use of imaging
techniques can be critical to facilitate a diagnosis
of internal hernias. Computed tomography (CT)
has become the first-line imaging technique of
choice because of its availability, speed, and
multiplanar reformatting capabilities[8]. Although
CT scanning is useful in identifying these herniations,
surgical exploration is the only means of obtaining
a definitive diagnosis.

Fig 1. Chest and abdominal x-ray showing

dilatation of the bowel loops.

CASE REPORT
A 3-month-old female patient with no known
congenital anomalies or systemic diseases presented
to the emergency department. According to her
mother, the patient had suffered from poor peripheral
circulation, was pale in complexion for 2~3 hours,
became irritable, and had a poor appetite in the
10 hours before treatment was sought. Routine
testing of the patient's stool and a stool morphology
analysis revealed no abnormal findings. A capillary
refilling time of > 6 s was noted during the patient's
initial evaluation. The patient initially received
treated abdominal pain. The patient's condition
continued to deteriorate, and she was transferred
to the pediatric intensive care unit.
After admission, a plain abdominal x-ray
revealed dilatation of the patient's bowel loops
(Fig. 1). The abdominal closed-table view (Fig. 2)
revealed the presence of several air-fluid levels in

124

Fig 2. Abdominal closed-table view showing

several air-fluid levels in the abdomen.
the abdomen. Further examinations were performed
to rule out ileus. There was no obvious free air in
the abdomen, and ileus was ruled out (Fig. 3).
Abdominal ultrasonography revealed dilated, fluidfilled bowel loops which were suspected of being
mechanical ileus caused by compression. There
was no evidence of intussusception. CT imaging
of the abdomen revealed diffuse dilatation of the
small-bowel loops (Figs. 3, 4).
The patient's symptoms persisted, and further

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Mesenteric Defect With Internal Herniation

Fig 3. Abdominal CT.

Fig 4. Abdominal CT showing diffuse

dilatation of the small-bowel loops

Fig 6. Small-intestinal necrosis.

Fig 5. Chest and abdominal x-ray showing

diffuse dilatation of the small-bowel
loops.
plain abdominal x-ray (Fig. 5) and abdominal closed
table view were performed. A surgical consult was
arranged,andexplorativelaparotomywassubsequently
performed. During the procedure a congenital
mesenteric defect with internal herniation was
observed, along with a small amount of intestinal

8 2 2010

necrosis and bloody ascites (Fig. 6). An intestinal

segmental resection with an enterostomy was then
performed. The final pathological diagnosis was
small intestinal hemorrhagic necrosis. Microscopic
analysis of necrosis intestine revealed transmural
hemorrhagic necrosis with prominent vascular
congestion. The mesentery also exhibited marked
evidence of hemorrhaging with dilated and congested
blood vessels. The margins of the bilateral section
revealed ischemic changes. There was no evidence
of a malignancy. The duration of the surgical
procedure was approximately 3 hours.
Postoperative antibiotics were prescribed for

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Chih-An Chen

Lung-Huang Lin

Te-Fang Chen

Shin-Hung Huang

7 days (intravenous vancomycin [40mg/kg/day],

Ceftazidime[150 mg/kg/day], and Metronidazole
[30 mg/kg/day]). The patient began consuming a
soft diet 6 days after the surgery without incident.
Wound healing was fair and the feeding status had
almost returned to normal 10 days after surgery.
The patient was discharged from the hospital 13
days after surgery and was followed-up in the
outpatient department on a weekly basis. After
discharge, her feeding returned to original amount,
and no further abdominal distension or vomiting
was found. Daily activities and the peripheral
circulation also returned to normal.

DISCUSSION
Internal hernias have been reported to be
associated with a mortality rate exceeding 50% in
some series. This type of herniation may be persistent
or intermittent. Internal hernia is a rare cause of
small bowel obstruction, with a reported incidence
ranging 0.2%~0.9%[6,9].
Mesocolic or transmesenteric hernias occur
due to iatrogenically created mesenteric defects. A
significant increase in hernias is evident in patients
undergoing transmesenteric, transmesocolic, and
retroanastomotic surgical procedures[1]. These
hernias are common following abdominal surgery,
especially Roux-en-Y loop reconstruction, during
which a mesenteric defect may be created[6].
Due to their rarity, diagnoss internal abdominal
herniations remains a challenge for both the clinician
and radiologist alike[10]. Symptoms of internal
herniation are nonspecific, ranging from mild
abdominal discomfort or nausea alternating with
episodes of intense abdominal pain to cramping
and abdominal pain. Because of these vague clinical
manifestations and the low incidence of internal
hernias, a preoperative diagnosis may be missed or
delayed, resulting in patient death.

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Although various radiologic examinations are

used to aid the timely diagnosis of internal herniation,
CT is widely believed to be the optimal diagnostic
technique[11]. A barium study and CT examination
of these hernias may also show the point of transition
where the bowel loops enter or exit the orifice.
Angiography can reveal altered jejunal vessels along
the herniated portion of the bowel. In patients
course with a history of recurrent and unexplained
subileus attacks with an undetermined cause of
obstruction, carefully performed CT and/or
enteroclysis may be the optimal diagnostic technique
(s) [10].
Treatment of hernias involves reduction of the
hernia and closure of the defect. In closing the
defect, care must be taken to prevent injuring
vessels near the margin of the hernial sac. For
internal hernias, the optimal treatment approach
involves correcting all mesenteric defects and any
malrotation abnormalities that are incidentally
found[11].
In conclusion, this report has reviewed the
clinical features, management, and therapeutic
outcomes of congenital and acquired internal
hernias. In this case, we found that sometimes the
usual signs may underlie some problems. In addition,
the difficulties in diagnosis and the features of
various types of hernias were discussed with
comments made regarding prevention of the acquired
forms of these rare hernias, along with the embryologic
background and methods of management for the
various congenital defects[12].

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J Pediatr Surg 2008;43:755-758.

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Lung-Huang Lin

Te-Fang Chen

Shin-Hung Huang

1,2,*

3 4

X X

( 20108 (2)123-128)

1 2
2010 03 23 2010 06 05
*LHLINLH@yahoo.com.tw

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