Figure 1
Non-enhanced CT, axial plane of abdomen and pelvis
Mesenteric volvulus in conjunction with an inguinal hernia in a female
SectionAbdominal imaging
Case TypeClinical Cases
AuthorsRoopkamal Sidhu, Ankush Dhanadia,Harshad Shah, Nirmala Chudasama
Connected authors
50 years, female
Clinical History
A 50-year-old female patient presented with complaint of swelling in left inguinal region for past 10 years. Sudden onset pain in lower abdomen for 2 days. Clinically no tenderness and no redness over the swelling. No history of constipation or previous surgery. Clinically a femoral hernia was suspected.
Imaging Findings
Non-enhanced CT scan of the abdomen and pelvis revealed a 8.7cm x 7.2cm (in axial plane) pseudo-mass formed by thickening and twisting of mesentry along its axis. It was located in the left anterior peroneal cavity. The pseudo-mass seemed to herniate through the left inguinal canal, up to the groin. The femoral canals on both sides and right inguinal canal appeared clear. The SMA and SMV appeared normal.
On enhanced CT examination, the bowel walls appeared normal with no signs of ischaemia or herniation. No ascites or lymphadenopathy was noted.
On enhanced CT examination, the bowel walls appeared normal with no signs of ischaemia or herniation. No ascites or lymphadenopathy was noted.
Discussion
1. Inguinal hernias:
- Indirect inguinal hernia occurs through inguinal canal extending into scrotal sac or anterior peroneal cavity. It is lateral to inferior epigastric vessels. Usually it occurs due to the failure of obliteration of processus vaginalis [1]
- Direct inguinal hernia occurs due to an acquired defect in transversalis fascia of Hesselbach triangle. It is medial to inferior epigastric vessels. Usually it is more common in middle-aged men [2]
2. Femoral hernia occurs through the femoral canal medial to the femoral vein.
It represents only 4% of all groin hernias and is found more often in women, usually on the right side.
Clinical Features: Fullness, symptoms of bowel obstruction/ischaemia [2]
Imaging Findings on CT:
Bowel and/or omentum (fat) or sometimes visceral organs protruding through peritoneum. Bowel or fat in hernia sac can be demonstrated. Stranding of fat suggest the possibility of incarceration. There may be proximal bowel dilatation from obstruction [3]. Bowel wall thickening, extraluminal fluid, severe fat stranding and engorged mesenteric vessels suggest strangulation [4].
Mesenteric volvulus is defined as the twisting of mesentery along its axis. It is an uncommon but potentially life-threatening condition, requiring urgent surgical intervention to prevent bowel obstruction and/or ischaemia. It may be primary, without an associated underlying cause, or secondary to a congenital or acquired condition, as in inguinal hernia seen in our case. The presence of long mobile mesentery and dietary factors may contribute to the volvulus [1, 2].
Ultrasound and CT are useful modalities for diagnosis [2]. Once the diagnosis is made, prompt surgical intervention is required to either lyse adhesions, dextorse the bowel, or formally resect and anastomose the bowel if it is found to be ischaemic. [3]
Ischaemia and/or infarction are life-threatening complications of volvulus. CT may in 70% of cases provide useful signs [2, 3], however early surgical management is the key for recovery.
- Indirect inguinal hernia occurs through inguinal canal extending into scrotal sac or anterior peroneal cavity. It is lateral to inferior epigastric vessels. Usually it occurs due to the failure of obliteration of processus vaginalis [1]
- Direct inguinal hernia occurs due to an acquired defect in transversalis fascia of Hesselbach triangle. It is medial to inferior epigastric vessels. Usually it is more common in middle-aged men [2]
2. Femoral hernia occurs through the femoral canal medial to the femoral vein.
It represents only 4% of all groin hernias and is found more often in women, usually on the right side.
Clinical Features: Fullness, symptoms of bowel obstruction/ischaemia [2]
Imaging Findings on CT:
Bowel and/or omentum (fat) or sometimes visceral organs protruding through peritoneum. Bowel or fat in hernia sac can be demonstrated. Stranding of fat suggest the possibility of incarceration. There may be proximal bowel dilatation from obstruction [3]. Bowel wall thickening, extraluminal fluid, severe fat stranding and engorged mesenteric vessels suggest strangulation [4].
Mesenteric volvulus is defined as the twisting of mesentery along its axis. It is an uncommon but potentially life-threatening condition, requiring urgent surgical intervention to prevent bowel obstruction and/or ischaemia. It may be primary, without an associated underlying cause, or secondary to a congenital or acquired condition, as in inguinal hernia seen in our case. The presence of long mobile mesentery and dietary factors may contribute to the volvulus [1, 2].
Ultrasound and CT are useful modalities for diagnosis [2]. Once the diagnosis is made, prompt surgical intervention is required to either lyse adhesions, dextorse the bowel, or formally resect and anastomose the bowel if it is found to be ischaemic. [3]
Ischaemia and/or infarction are life-threatening complications of volvulus. CT may in 70% of cases provide useful signs [2, 3], however early surgical management is the key for recovery.
Differential Diagnosis List
Mesenteric volvulus in conjunction with a left-sided inguinal hernia in an elderly woman
Femoral hernia
Transmesenteric hernia
Final Diagnosis
Mesenteric volvulus in conjunction with a left-sided inguinal hernia in an elderly woman
References
[1] John T. Henkins, Patrick J O\'Dwyer (2008) Inguinal hernias. British Medical Journal 336(7638) : 269-272 (PMID: 18244999)
[2] Burkhardt J, Arshanskiy Y, Munson JL, Scholz FJ. (2011) Diagnosis of inguinal region hernias with axial CT: the lateral crescent sign and other key findings. Radiographics 31(2):E1-12 (PMID: 21415178)
[3] M. Uludag et al. (2006) A rare cause of intestinal obstruction: incarcerated femoral hernia, strangulated obturator hernia. Hernia -European Hernia Society (GREPA) Volume 10, Issue 3, pp 288-291 (PMID: 16520887)
Case information
| URL: | https://www.eurorad.org/case/11830 |
| DOI: | 10.1594/EURORAD/CASE.11830 |
| ISSN: | 1563-4086 |
Figure 2
Venous phase, CT coronal reformatted image of abdomen and pelvis
Figure 3
Non-enhanced CT, axial plane of abdomen and pelvis
Herniation of pseudo-mass into the left peroneal cavity, at the level of left groin.
Non-enhanced CT, axial plane of abdomen and pelvis
Venous phase, CT coronal reformatted image of abdomen and pelvis
Mesentery herniating through left inguinal canal. Bowel loop thickness and enhancement are normal, suggestive of absence of ischaemia or obstruction. Right hernial orifice is clear.
Sidhu R, C.U.Shah Medical College and Hospital, Gujarat, India
Sidhu R, C.U.Shah Medical College and Hospital, Gujarat, India
Left femoral triangle reveals absence of herniation, ruling out the possibility of femoral hernia.
Sidhu R, C.U.Shah Medical College and Hospital, Gujarat, India.
Sidhu R, C.U.Shah Medical College and Hospital, Gujarat, India.
Non-enhanced CT, axial plane of abdomen and pelvis
Herniation of pseudo-mass into the left peroneal cavity, at the level of left groin.
Sidhu R, C.U.Shah Medical College and Hospital, Gujarat, India.
Sidhu R, C.U.Shah Medical College and Hospital, Gujarat, India.
Venous phase, sagittal reformatted image of abdomen and pelvis
The SMA and SMV appear normal. The pseudo-mass lies in the anterior peroneal cavity.
Sidhu R, C.U.Shah Medical College and Hospital, Gujarat, India
Sidhu R, C.U.Shah Medical College and Hospital, Gujarat, India
Further down the course of SMA we can see that the characteristic whirlpool sign of SMA SMV is absent due to uninvolvement.
Sidhu R, C.U.Shah Medical College and Hospital, Gujarat, India
Sidhu R, C.U.Shah Medical College and Hospital, Gujarat, India