A 52-year-old man presented to the emergency department complaining of an 8-hour history of progressive, crampy, epigastric, and periumbilical abdominal pain. He reported nausea but no vomiting. He continued to pass flatus and had a normal bowel movement the day prior to admission. On presentation, the patient was afebrile with normal vital signs. Physical examination was significant for high-pitched bowel tones, mild abdominal distention, and diffuse tenderness without peritoneal signs. Laboratory studies showed leukocytosis (14 500 cells/mL) with elevated bands. Acute abdominal series showed multiple dilated small-bowel loops with air-fluid levels. Computed tomography scans of the abdomen and pelvis showed dilation of the stomach and small bowel and distal decompressed bowel in the pelvis with a transition point in the left lower quadrant. Diagnostic laparoscopy revealed a loop of distal small bowel herniating through an approximately 4-cm defect in the medial peritoneal leaflet of the sigmoid mesocolon (Figure 1and Figure 2).
Distal ileum herniating through medial peritoneal leaflet of sigmoid mesentery.
Hernia defect with reduced distal ileum.
A. Paraduodenal hernia
B. Intersigmoid hernia
C. Transmesosigmoid hernia
D. Intramesosigmoid hernia
Taras A, Martinez R. Image of the Month—Quiz Case. Arch Surg. 2009;144(12):1187–1188. doi:10.1001/archsurg.2009.200-a