Stomach in the Pelvis - Itʼs Not A Joke!

Abstract

Introduction: We report a rare case of massive gastric dilatation secondary to closed loop small bowel obstruction caused by internal hernia leading to obstruction of biliary intestinal limb of Whipple procedure. Case Report: A 59-year-old woman with multiple abdominal surgeries including sigmoid colectomy for sigmoid volvulus, pylorus preserving Whipple surgery for pancreatic hamartoma 3 years prior, presented with nausea, vomiting, constipation and periumbilical abdominal pain for 2 days. Examination was remarkable for tachycardia and soft but distended abdomen, diffuse tenderness and hypoactive bowel sounds. Lab evaluation showed WBC 14 K/μl and creatinine 2.62 mg/dl. Nasogastric tube placement yielded 4 l bilious fluid in the first hour. CT scan of abdomen demonstrated massively distended stomach, measuring 15 cm transversely, 14 cm antero-posteriorly and 35 cm craniocaudally extending into the pelvis with proximal small bowel dilatation. Patient responded to conservative management and small bowel follow through study performed 48 hours later showed marked decompression of the stomach. Six weeks later, patient was readmitted with similar clinical presentation. CT scan showed evidence of gastric distension and partial bowel obstruction in the mid anterior abdomen involving multiple segments of small bowel. She did not respond to conservative management for 10 days and laparotomy was performed later on. Laparotomy revealed small bowel closed loop obstruction due to internal hernia, obstructing the biliary limb of Whipple procedure adjacent to the gastrojejunostomy. Discussion: Closed loop obstruction is a rare type of bowel obstruction associated with high mortality of 35% at 36 hours of delayed diagnosis. Internal hernia is an uncommon cause of bowel obstruction reported in 0.2% to 0.9% of autopsies and in 0.5-4.1% of cases of intestinal obstruction. Internal hernia cause closed loop obstruction when the narrow defect causes occlusion of the loops of small bowel entering and exiting through mesenteric defect or congenital mesenteric opening. Postsurgical adhesions can cause more narrowing of the defect. We present a very unusual case of closed loop intestinal obstruction of the biliary limb of Whipple procedure that in addition lead to massive gastric distension of stomach.Figure: CT scan with oral contrast.