An unusual case of small bowel obstruction secondary to internal herniation of distal ileum through a rent between adhered inflamed vermiform appendix and appendices epiploicae
Keywords:Intestinal obstruction, Small bowel obstruction, Internal hernia, Appendices epiploicae, Epiploic appendagitis
Intestinal obstruction secondary to an internal hernia is rare and that occurring through a rent between the adhered inflamed vermiform appendix and appendices epiploicae of the proximal caecum is so rare that this case was the first of its kind ever to be reported. Such a cause for obstruction should be suspected in a patient with a virgin abdomen with no history/clinical features of an obstructing external hernia or abdominal tumor. A 28 year old man presented to the ER with features of intestinal obstruction, in whom CECT abdomen revealed multiple dilated small bowel loops with breaking-of seen in the region of the terminal ileum. Surgical exploration revealed internal herniation of the distal ileum through a rent between the adhered inflamed vermiform appendix and the appendices epiploicae of the proximal caecum; reduction of which was sufficient to relieve the obstruction and demonstrate healthy reperfusion. Adhesiolysis, epiploicae appendectomy and appendectomy was done with no other points of obstruction along the small bowel. Due to its rarity, non-specific presentation pattern and limited usefulness of imaging for diagnosis, a high index of suspicion with prompt early surgical exploration is a must for a successful outcome in such cases intestinal obstruction; especially in a virgin abdomen.
Liu CH, Wang SY. Ileal herniation into a sigmoid colon epiploic fat foramen extrasigmoid hernia. Tech Coloproctol. 2004;8(2):106-8.
Sand M, Gelos M, Bechara FG, Sand D, Wiese TH, Steinstraesser L, et al. Epiploic appendagitis-clinical characteristics of an uncommon surgical diagnosis. BMC Surg. 2007;7:11.
Suzuki Y, Katagiri H, Yoshinaga Y, Lefor AT, Mizokami K. Internal hernia caused by epiploic appendices successfully treated by single-incision laparoscopic surgery (SILS). Hernia. 2015;19(6):1011-3.
Kulacoglu H, Tumer H, Aktimur R, Kusdemir A. Internal herniation with fatal outcome: herniation through an unusual aperture between epiploic appendices and greater omentum. Acta Chir Belg. 2006;106(1):109-11.
Lau JT, Ong GB. Bowel herniation through a defect in the appendices epiploicae. J R Coll Surg Edinb. 1984;29(3):187-8.
Krijgsman B, Salter MC. Internal herniation through a colonic epiploica. Surgery. 1997;122(3):643.
Oneyama M, Sekikawa K, Goto M, Kitamura M, Ohta R, Takawashi Y. A case of ileus due to an internal hernia caused by a sigmoid colon epiploic appendix. J Jpn Surg Assoc. 2011;72(12):3175-9.
Srivastava KN, Agarwal A, Roopesh D, Prashad R. An unusual case of intestinal obstruction due to internal herniation from adhesions between two appendices epiploicae. J Surg Case Rep. 2018;9(8):1-3.
Ghahremani GG. Internal abdominal hernias. Surg Clin North Am. 1984;64(2):393-406.
Newsom BD, Kukora JS. Congenital and acquired internal hernias: unusual causes of small bowel obstruction. Am J Surg. 1986;152(3):279-85.
Ghahremani GG, White EM, Hoff FL, Gore RM, Miller JW, Christ ML. Appendices epiploicae of the colon: radiologic and pathologic features. Radiographics. 1992;12(1):59-77.