Internal abdominal hernias in childhood.

Abstract

Abdominal pain, one of the most frequent complaints in childhood, represents a particular problem when episodic symptoms persist for more than 3 months. According to Boyle (1), ≈10-15% of school-age children suffer from chronic recurrent abdominal pain of complex etiology. Intra-abdominal hernias are not frequently observed and are difficult to diagnose. CASE REPORTS The following report describes five patients with intra-abdominal hernias treated at this hospital between 1979 and 1994. Case 1 At the age of 1 year, the patient was admitted to the hospital for colic abdominal pain with a presumptive diagnosis of intussusception. Clinical and radiological examination were non-confirmatory. From the age of 5, the patient again had episodes of recurrent abdominal pain. On admission to our hospital he was 9 years old. A visible bulge of rough consistency was noted during an acute attack, 6-8 cm below the right costal margin. A fast recovery ensued when the patient was brought into a knee-elbow position. Ultrasound examination was unremarkable during the pain-free interval. An upper gastrointestinal series showed a hypotonic stomach and an impression in the descending part of duodenum from the ventral and right lateral areas immediately after a painful episode. X-ray examination 20 h later revealed that contrast medium was still in the antrum and bulbus duodeni. Delay in gastric emptying and hindering of intestinal progression by duodenal impression from the outside was found (Figs. 1 and 2). Intraoperatively, an internal hernia was detected in the region of the foramen Winslowi. Case 2 A 4-week-old boy was admitted to the hospital, having vomited several times on the day of admission and then refused further feedings. The upper abdomen was distended without increased peristaltic waves. The results of all laboratory studies were normal. Abdominal sonography showed very active gastric peristaltic waves but no pyloric stenosis. Behind the stomach, an atypically located intestinal segment was identified (Fig. 3). Increased gastric peristalsis was confirmed by an upper gastrointestinal series. The duodenum was filled regularly, though no further transport was observed in the ascending part. Retropulsive peristalsis was observed. Thirty minutes later an exceedingly small jejunum was demonstrated. The presumptive diagnosis of an internal hernia in the region of the foramen Winslowi was confirmed intraoperatively. Case 3 A 15-year-old girl was admitted to the hospital. Five months previously she had complained for the first time of acute pain in left flank, radiating toward the back. Two and four months later, attacks of abdominal pain reappeared. Diagnostic examination at another hospital revealed only an absolute eosinophilia of 6160/μl. The upper gastrointestinal series was normal. Gastritis and duodenitis with bile reflux were found by gastroscopy. Paracentesis of bone marrow showed unspecific eosinophilia. Antibiotic treatment with clotrimazol reduced the leucocytosis and eosinophilia. Six weeks later, the patient experienced another episode of pain. She underwent endoscopy repeatedly, but the findings were nonspecific. Computed tomography of the abdomen revealed only an isolated lymphatic node enlargement. Eosinophilia was present. The patient was treated with analgesics. Because placebos produced a comparable effect, a functional reason for the abdominal pain was suggested. At the time of admission to our hospital, the girl was in good condition in spite of severe pain, mainly in the left paraumbilical and supraumbilical regions. Laboratory findings demonstrated eosinophilia (2,349/μl) and a high IgE of 549 IU/ml (normal age-related level ≤260 IU/ml). The results of orthopedic and gynecological examination were normal. Abdominal sonography demonstrated a distinct duodenal dilatation with a coarsened mucosa and pendulum peristalsis during a pain-free interval. Furthermore, an intestinal loop was shown in an atypical location on the dorsal side of the stomach. Application of water increased the duodenal filling, pendulum peristalsis, and reflux into the stomach. An upper gastrointestinal series showed a broad duodenum with thickened mucosa. The pendulum peristalsis was also detected during an episode of pain while contrast medium was moving in small fractions into the jejunum (Fig. 4). In addition, a small intestinal conglomeration (Fig. 5) was visible located behind the stomach. The presumptive diagnosis of an intra-abdominal hernia was made preoperatively. The diagnosis of transverso-mesocolical hernia was confirmed intraoperatively. The peritoneum showed injected vessels in the hernial orifice region (Fig. 6, a and b). Following surgery, both the episodic abdominal pain and the eosinophilia subsided. Case 4 A 6½-year-old girl presented with a 5-week history of epigastric abdominal pain and retrosternal tenderness. The epigastric pain appeared immediately after meals. The results of physical examination were normal except for increased peristalsis. Laboratory findings showed no signs of inflammation, and all blood values were normal. During the symptom-free interval, repeated ultrasonography of the abdomen and mediastinum, and upper gastrointestinal series, were normal. Examination during an acute attack demonstrated retroperistalsis in the duodenum without propulsion. One intestinal segment was located behind the prepyloric antrum. A paraduodenal hernia was suspected and was confirmed intraoperatively. Case 5 A 4-week-old female infant was admitted to the hospital in a markedly reduced physical condition. The patient had not been well for 2 weeks. The laboratory findings were noncontributory. A recurrent, but not projectile vomiting, and alternating diarrhea and constipation were noticed. Intussusception was shown radiologically. In addition, a mobile cecum was demonstrated by barium enema. Furthermore, the gastrointestinal series showed a prestenotic dilatation of the ileum (Fig. 7) and a right-sided displacement in the ileocolic valve area. At laparatomy, a connective tissue- and cord-like induration was found in the stenotic region. Vessels, histologically identified inside of those fibrous cords, indicated the mesenteric nature. Thus, the diagnosis of retrocoecal hernia was established. DISCUSSION Intra-abdominal hernias are a rare cause of chronic or acute abdominal pain in childhood. Hansmann and Morton (2) reported 467 cases, though no information is available about the age of these patients. A 12-year-old boy with a paraduodenal hernia is mentioned in a recent survey of 14 patients (3). Anatomically, six different types of intraabdominal hernias are distinguished: The left- and right-sided paraduodenal hernias and the transverso-mesenteric hernias account for >50% of all intra-abdominal hernias in adults and probably represent the most frequent form of internal hernia in children. Paracecal hernias occur through the foramen of Winslowi. Pelvic and mesosigmoidal hernias are additional causes of intra-abdominal hernias. Gullino (3) differentiates normal and paranormal hernias from abnormal hernias. Normal intestinal hernias leave the peritoneal cavity through a physiological foramen (e.g., the foramen Winslowi). Paranormal hernias go through a peritoneal orifice, which expands with increasing age (e.g., paraduodenal hernias through the foramen of Landzert or the foramen Waldeyer). Both types of hernias have a peritoneal sac. The hernial orifice and hernial sac are lower in the abdominal cavity, as is emphasized by Waldschmidt (4). “Inner prolapse” is called a hernia in a peritoneal orifice resulting from a postoperative condition or an inflammation. Two etiological concepts are put forward to explain the origin of internal hernias. The formation of internal hernia is combined with a malrotation of the gut according to an embryonal concept (5-7). Alternatively, an abnormal dilatation of a physiological peritoneal orifice is discussed, e.g., hernias into the foramen of Waldeyer or the foramen of Landzert. The frequency of intraabdominal hernias is unknown. Freund et al. (8) postulate that the overall incidence is underestimated, since frequently intra-abdominal hernias remain unnoticed. It is estimated that 0.5-3% of intestinal obstructions are due to internal hernias. According to Waldschmidt, 30% of the cases remain without symptoms for the lifetime. Thus, hernias are found incidentally in 0.2-0.9% of autopsies (9). A third of patients are symptom free, and another third have acute clinical symptoms of intestinal obstruction, including ileus. The remaining third experience chronic abdominal pain, recurrent vomiting, and alternating diarrhea and constipation (4). Since Murphy's paper (10), about 30 case reports have been published. He mentioned 11 children from the ages of several hours to 6 years and emphasized a coincidence with intestinal atresias. Modern radiological methods were not provided for any of the 11 children (10). In none of these cases was a precise presurgical diagnosis possible. The clinical symptoms of internal hernias are very variable. Iuchtmann et al. (11) report a neonatal presentation. Moore (12) describes an internal hernia with intestinal obstruction following an antenatal meconium peritonitis. In older children, left- (13) or right-sided paraduodenal hernias (14), hernias associated with Meckel's diverticulum (15), and cecal hernias (16) are described. One complication of internal hernias can be gastrointestinal hemorrhage in childhood (17). Pfalzgraf et al. (18) discuss internal hernias as a cause of “sudden infant death” in two patients. Strangulation of intestinal segments is reported as another complication of internal hernias (e.g., 19,20). Internal hernias can also be seen secondary to operative interventions (21,22). Posttherapeutic adhesions of the small intestine were noted following surgical treatment and radiotherapy of two patients with Wilm's tumors (23). The possibility of diagnosis of paraduodenal hernia in children through computed tomography is described (24). Most authors mention the difficulty of preoperative diagnosis. Apart from clinical symptoms, radiological procedures are most useful. A plain X-ray film of the abdomen and the use of intestinal contrast medium may show displaced small intestinal loops or aggregation or absence of small intestinal loops in the pelvic area. Further evidence of obstruction can be found, such as a prestenotic dilatation, slow transit time (e.g., paraduodenal hernias), delayed emptying of the stomach, and retrograde peristalsis. Apart from conventional procedures are described in our case reports 1 and 3, angiography has been used (25), as well as abdominal computed tomography (26) and, more recently, ultrasonography (27). Contrary to the work of Wachsberg, we could not directly confirm the hernial sac in our documentation from cases 2 and 4, but we found duodenal dilatation, retrograde peristalsis, and localization of intestine in atypical positions between the pancreas and the stomach (cases 3 and 4) or near to the duodenum (case 2). Ultrasonography demonstrated an internal hernia in case 4, which was later proven intraoperatively without additional invasive diagnostic procedures. Surgery is the therapy of choice in the treatment of intra-abdominal hernias. Even in the case of a small hernia or an incidentally intraoperative diagnosis, a surgical procedure is recommended, because a 50% mortality rate is reported when acute clinical symptoms are present. Intraoperatively, the internal hernias are localized by the intra-abdominal vessels leading into the hernial orifice and by a concomitant or even a causative intestinal malrotation (7). Laparoscopic operation of internal hernias is performed in some cases (28) but is not recommended by us for children.FIG. 1: . Upper gastrointestinal series: hypotonic stomach, impression of the descending part of the duodenum.FIG. 2: . Delayed gastric emptying up to 20 h after ingestion of contrast medium.FIG. 3: . Sonographic representation of air in an intestinal loop (arrow) behind the stomach.FIG. 4: . Discontinuous passage of contrast medium in duodenum with retropulsive peristalsis, showing thickened duodenal mucosa and duodenal dilatation. Disconnected contrast medium passage between duodenum and jejunum.FIG. 5: . Displacement of jejunal loops behind the stomach.FIG. 6. A:: Transverso-mesocolical hernial orifice with peritoneal injected vessels. B: Intestinal hernia into the hernial orifice.FIG. 7: . Contrast medium shows large intestine and terminal ileum; right-sided displacement of ileum as sign of a retrocecal hernia with prestenotic dilatation.