Postpartum Internal Hernia
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Marianna G. Mavilia
A 32-year-old woman (gravida 2, para 2) presented with severe, midepigastric abdominal pain that began 3 hours after delivery. Her surgical history was significant for laparoscopic Roux-en-Y gastric bypass (LRYGB) 4 years earlier. An axial computed tomographic (CT) image of the abdomen depicted twisting of central mesentery and origin of the “swirl” (image A, arrow). A coronal CT image of the abdomen also depicted twisting of central mesentery and the “swirl” (image B, circle), along with small bowel dilatation. An internal hernia (IH) was discovered during laparotomy, and 110 cm of ischemic small bowel was resected and left in discontinuity. A second laparotomy performed the next day confirmed viable small bowel tissue, and the patient underwent a stapled end-to-end primary anastomosis. She recovered and was discharged home.
The risk of IH after LRYGB is well-documented.1,2 The swirl sign is a radiographic finding that accurately predicts the occurrence of IH with a sensitivity of 78% to 100% and a specificity of 80% to 90%3 and is characterized by a clustering of small bowel loops at the mesenteric root.1-3 The “swirl sign” seen on a CT image should be considered as an IH in patients who have had LRYGB. Imaging studies should be considered early to rule out IH in this patient population.
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Financial Disclosures: None reported.
References
1 Bauman RW Pirrello JR . Internal hernia at Petersen's space after laparoscopic Roux-en-Y gastric bypass: 6.2% incidence without closure—a single surgeon series of 1047 cases. Surg Obes Relat Dis.2009;5(5):565-570. doi:10.1016/j.soard.2008.10.013.10.1016/j.soard.2008.10.013Search in Google Scholar PubMed
2 Carmody B DeMaria EJ Jamal M et al. . Internal hernia after laparoscopic Roux-en-Y gastric bypass. Surg Obes Relat Dis.2005;1(6):543-548.10.1016/j.soard.2005.08.005Search in Google Scholar PubMed
3 Iannuccilli JD Grand D Murphy BL Evanelista P Roye GD Mayo-Smith W . Sensitivity and specificity of eight CT signs in the preoperative diagnosis of internal mesenteric hernia following Roux-en-Y gastric bypass surgery. Clin Radiol.2009;64(4):373-380. doi:10.1016/j.crad.2008.10.008.10.1016/j.crad.2008.10.008Search in Google Scholar PubMed
© 2014 The American Osteopathic Association
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- Editorial
- Reevaluating Osteopathic Medical Education for the 21st Century and Beyond
- Special Report
- A Single Graduate Medical Education Accreditation System: Ensuring Quality Training for Physicians and Improved Health Care for the Public
- Letters
- Unified Graduate Medical Education Accreditation: A Better Plow
- Moving From EBM to EBOM: An Osteopathic Perspective on Evidence-Based Medicine
- Correction
- Correction
- Medical Education
- Preliminary Outcomes of the Lake Erie College of Osteopathic Medicine's 3-Year Primary Care Scholar Pathway in Osteopathic Predoctoral Education
- Student- and Faculty-Reported Importance of Science Prerequisites for Osteopathic Medical School: A Survey-Based Study
- Consistency of Interrater Scoring of Student Performances of Osteopathic Manipulative Treatment on COMLEX-USA Level 2-PE
- Relationship Between COMLEX-USA Scores and Performance on the American Osteopathic Board of Emergency Medicine Part I Certifying Examination
- Concurrent Validity of the Osteopathic General Surgery In-Service Examination
- Keyboard Data Entry Use Among Osteopathic Medical Students and Residents
- Colleges of Osteopathic Medicine: Substantive Changes—An Update
- Citation and Correction of Deficiencies in Osteopathic Graduate Medical Education Programs: Opportunities for Improvement
- AOA Continuing Medical Education
- Appendix
- Appendix 1: Osteopathic Graduate Medical Education 2014
- Appendix 2: Dual and Parallel Postdoctoral Training Programs
- Appendix 3: AOA Specialty Board Certification
- Appendix 4: Colleges of Osteopathic Medicine
- Clinical Images
- Takotsubo Cardiomyopathy
- Postpartum Internal Hernia
Articles in the same Issue
- Editorial
- Reevaluating Osteopathic Medical Education for the 21st Century and Beyond
- Special Report
- A Single Graduate Medical Education Accreditation System: Ensuring Quality Training for Physicians and Improved Health Care for the Public
- Letters
- Unified Graduate Medical Education Accreditation: A Better Plow
- Moving From EBM to EBOM: An Osteopathic Perspective on Evidence-Based Medicine
- Correction
- Correction
- Medical Education
- Preliminary Outcomes of the Lake Erie College of Osteopathic Medicine's 3-Year Primary Care Scholar Pathway in Osteopathic Predoctoral Education
- Student- and Faculty-Reported Importance of Science Prerequisites for Osteopathic Medical School: A Survey-Based Study
- Consistency of Interrater Scoring of Student Performances of Osteopathic Manipulative Treatment on COMLEX-USA Level 2-PE
- Relationship Between COMLEX-USA Scores and Performance on the American Osteopathic Board of Emergency Medicine Part I Certifying Examination
- Concurrent Validity of the Osteopathic General Surgery In-Service Examination
- Keyboard Data Entry Use Among Osteopathic Medical Students and Residents
- Colleges of Osteopathic Medicine: Substantive Changes—An Update
- Citation and Correction of Deficiencies in Osteopathic Graduate Medical Education Programs: Opportunities for Improvement
- AOA Continuing Medical Education
- Appendix
- Appendix 1: Osteopathic Graduate Medical Education 2014
- Appendix 2: Dual and Parallel Postdoctoral Training Programs
- Appendix 3: AOA Specialty Board Certification
- Appendix 4: Colleges of Osteopathic Medicine
- Clinical Images
- Takotsubo Cardiomyopathy
- Postpartum Internal Hernia
