II. Causes

  1. Roux-en-Y gastric bypass
    1. Intraabdominal Hernia near Gastric Bypass site with secondary ischemia and infarction of bowel

III. Epidemiology

  1. Occurs in up to 3% of retrocolic bypass procedures

IV. Pathophysiology

  1. Small Bowel trapped in Internal Hernia results in closed loop obstruction

V. Risk Factors

  1. Greatest post-surgical weight loss (exaggerates defects)
  2. Laparoscopic surgery (less adhesions)

VI. Types

  1. Peterson Defect (approximately 66% of cases)
    1. Occurs in the space between the mesentery and the overlying roux limb as it approaches the pouch
  2. Small Bowel anastomosis defect (approximately 33% of cases)
    1. Occurs in the space between the mesentary and the overlying Jejunostomy
    2. Higher risk of Small Bowel ischemia or infarction

VII. Signs: Presentation

  1. Most common in first 6-18 months post-operatively
  2. Presents with colicky Epigastric Pain that worsens with eating

VIII. Evaluation

  1. Requires urgent surgical Consultation

IX. Imaging: Abdominal CT with oral and IV contrast

  1. Positive findings are subtle
    1. Mesenteric edema
    2. Swirling mesenteric vessels
      1. Pathognomonic for Internal Hernia
      2. Represent bowel loops around the Internal Hernia site
  2. CT is only helpful if positive (often normal initially)
    1. Emergent surgery is indicated for a positive CT
  3. Negative result should not be considered reassuring
    1. Does not replace urgent Consultation with bariatric surgeon if Internal Hernia is suspected

X. Complications

  1. Critical Illness or death
  2. Short bowel syndrome (resection of necrotic Small Bowel)

XI. References

  1. Weinstock in Majoewsky (2012) EM:RAP 12(3): 3

Images: Related links to external sites (from Bing)

Related Studies

Ontology: Hernia of abdominal cavity (C0178282)

Definition (NCI) The protrusion of abdominal contents through a congenital or acquired defect in the abdominal wall.
Definition (MSH) A protrusion of abdominal structures through the retaining ABDOMINAL WALL. It involves two parts: an opening in the abdominal wall, and a hernia sac consisting of PERITONEUM and abdominal contents. Abdominal hernias include groin hernia (HERNIA, FEMORAL; HERNIA, INGUINAL) and VENTRAL HERNIA.
Concepts Anatomical Abnormality (T190)
MSH D046449
ICD9 550-553.99
ICD10 K46 , K46.9
SnomedCT 155758000, 196973008, 196968002, 196799009, 359801000, 155737006, 52515009, 30477007, 6515007
English Hernia of abdominal cavity, Abdominal cavity hernia NOS, Unsp.abd.cavity hernia NOS, Unspecified abdominal cavity hernia NOS, abdominal hernia, hernia of abdominal cavity, abdominal hernia (physical finding), abdomen hernia, intra-abdominal hernia, intra-abdominal hernia (diagnosis), Abdominal hernia NOS, Abdominal herniation, Unspecified abdominal hernia, Hernia, Abdominal [Disease/Finding], hernia abdominal, internal hernia, intraperitoneal hernia, abdominal hernias, abdominal herniation, Abdominal Hernia, Abdominal cavity hernia NOS (disorder), Unspecified abdominal cavity hernia NOS (disorder), Abdominal hernia, Internal hernia, Hernia of abdominal cavity (disorder), Intra-abdominal hernia (disorder), Intra-abdominal hernia, Intraperitoneal hernia, hernia; abdominal, Hernia of abdominal cavity, NOS, Intra-abdominal hernia, NOS, Hernia of abdominal cavity [Ambiguous], Abdominal Hernias, Hernia, Abdominal, Hernias, Abdominal, HERNIA OF ABDOMINAL CAVITY
Italian Ernia interna, Erniazione addominale, Ernia addominale NAS, Ernia addominale
Dutch abdominale hernia NAO, abdominale uitstulping, hernia; abdominalis, abdominale hernia, inwendige hernia, Niet gespecificeerde buikbreuk, Buikwandbreuk, Buikhernia, Hernia, buik-
French Hernie abdominale SAI, Hernie interne, Hernie abdominale, Hernie de la paroi abdominale, Laparocèle
German Hernia abdominalis NNB, abdominale Herniation, Nicht naeher bezeichnete abdominale Hernie, interne Hernie, Abdominalhernie, Hernia abdominalis
Portuguese Herniação abdominal, Hérnia abdominal NE, Hérnia abdominal, Hérnia interna, Hérnia Abdominal
Spanish Hernia abdominal NEOM, hernia de la cavidad abdominal, SAI, hernia de la cavidad abdominal no especificada, SAI, Abdominal cavity hernia NOS, hernia abdominal, hernia de la cavidad abdominal, SAI (trastorno), hernia de la cavidad abdominal no especificada, SAI (trastorno), hernia de la cavidad abdominal (trastorno), hernia de la cavidad abdominal, hernia intrabdominal (trastorno), hernia intrabdominal, Hernia abdominal, Hernia interna, Hernia Abdominal
Japanese 腹部ヘルニア形成, 腹部ヘルニアNOS, 内ヘルニア, 腹部ヘルニア, フクブヘルニア, フクブヘルニアNOS, ナイヘルニア, フクブヘルニアケイセイ
Swedish Bukbråck
Czech břišní kýla, hernie abdominální, Břišní výhřez, Břišní kýla NOS, Bišní kýla, Vnitřní kýla
Finnish Vatsatyrä
Korean 상세불명의 복부헤르니아
Croatian Not Translated[Hernia, Abdominal]
Polish Przepuklina brzuszna
Hungarian Abdominalis hernia, Abdominalis sérv k.m.n., Abdominalis herniatio, Belső hernia
Norwegian Magebrokk, Abdominalhernie, Hernie, abdominalt, Abdominalt brokk, Brokk, abdominalt, Hernia abdominalis