Roentgen diagnosis of intra-abdominal hernia; an evaluation of the roentgen findings.

Abstract

Internal hernias, i.e., hernias confined within the abdominal cavity, were first described by Hensing (2) in 1742. Later, Treitz established them as a clinical entity (1857). In 1899, Moynihan (5) listed nine fossae in the duodenojejunal region as possible sites for hernia. The incidence of internal hernia is not known, though it does occur more commonly than is generally believed. Watson (7) found 3 examples in 1,600 autopsies, and Mitchell (4) encountered one aperture in the mesentery, a potential hernia, in 400 autopsies. Presumably many go undetected. The possibility of radiologic diagnosis of internal hernia has been neglected by many roentgenologists when making routine gastrointestinal examinations. Clinicians, also, have been remiss in recognizing the associated clinical syndrome and have not referred cases to the rocntgenologist for small bowel studies, with this condition in mind. As a result, many internal hernias are overlooked. There are numerous positive roentgen signs of hernia and similar conditions which, when searched for and recognized, will lead to the diagnosis with a reasonable degree of accuracy. Steinke (6) outlined a simple classification of internal hernias, dividing them into retroperitoneal and anteperitoneal groups. Paraduodenal, paracecal, and intrasigmoid hernias and herniation through the foramen of Winslow are placed in the retroperitoneal group. Herniations through openings in the mesentery and omentum, and into the broad ligament, are placed in the anteperitoneal group. Seldom can the various types of hernia be differentiated roentgenologically. The one reasonably accurate sign is seen in the right paraduodenal hernias, in which the duodenum extends directly to the right from the bulb and the jejunum is displaced to the right and posteriorly. Symptomatology The symptoms are not specific, but in most cases are sufficiently characteristic to suggest the diagnosis. The usual history is of repeated attacks of epigastric discomfort or pain, accompanied by a feeling of distention, variable in periodicity and severity. Commonly, the patient has found that the discomfort may be altered or relieved by change in position, and that it is increased following a large meal but is not affected by the type of food. Nausea is not a constant symptom and usually occurs only in severe attacks. Vomiting is infrequent and in some cases is absent altogether. Appendicitis and duodenal ulcer have been suspected by the attending physician in some instances. One outstanding feature is the absence of clinical signs or laboratory data indicative of inflammatory disease. Usually the patient becomes symptom-free between attacks; rarely are the symptoms unremitting. Duration of symptoms in 40 cases of hernia and torsion studied by the writer has varied from three weeks to forty-one years.