International Journal of Surgery Case Reports 2 (2011) 51–52
Contents lists available at ScienceDirect
International Journal of Surgery Case Reports journal homepage: www.elsevier.com/locate/ijscr
Case report
Complete small bowel obstruction secondary to transomental herniation in pregnancy Tasneem Katawala ∗ , E.L. Hamlyn Queen Charlotte’s and Chelsea Hospital, Du Cane Road, London, W12 0HS, UK
a r t i c l e
i n f o
Article history: Received 24 January 2011 Accepted 25 January 2011 Available online 1 February 2011 Keywords: Transomental herniation Small bowel obstruction Internal hernia Pregnancy
a b s t r a c t During pregnancy, abdominal pain can be caused by both obstetric and non-obstetric causes. Nonobstetric causes of severe abdominal pain during pregnancy must always be considered. Complete bowel obstruction caused by an internal hernia is rare in obstetric surgical patients. Delays in diagnosis can occur due to non-specific signs and symptoms which can be present in normal pregnancy, and a reluctance to operate on the pregnant patient. Prompt diagnosis and early surgical intervention is the cornerstone for a good outcome. Surgical intervention during pregnancy is associated with increased risk of foetal loss. The use of intra-operative cardiotocography for foetal monitoring in non-obstetric surgery remains controversial. © 2011 Surgical Associates Ltd. Elsevier Ltd. All rights reserved.
1. Introduction Management of the acute abdomen can be challenging in obstetric patients. Physiological and anatomical changes associated with pregnancy make diagnoses extremely difficult, and there are risks to both mother and foetus associated with unnecessary surgical intervention. We report a case of complete small bowel obstruction secondary to transomental herniation of jejunum incidentally found in a pregnant woman with suspected appendicitis and perforation. 2. Case presentation A 37-year-old woman at 20 weeks gestation presented with a one-day history of lower abdominal pain and vomiting. Pain was colicky in nature, radiating to the right iliac fossa. On clinical examination, she was cardiovascularly stable and apyrexial. There was mild distension of her abdomen with rebound tenderness and guarding in the upper right quadrant and epigastrium. Bowel sounds were absent. Fundal height was consistent with 20week gravid uterus and foetal heart sounds were present. Abdominal X-ray showed no air under the diaphragm but dilated loops of bowel. Ultrasound revealed distended loops of bowel with free fluid in the upper abdomen; the appendix could not be seen. Blood tests revealed haemoglobin of 15.3 g/dl, white count of 14.9 × 109 /l, and platelet count of 222 × 109 /l, C-
∗ Corresponding author. E-mail address: [email protected] (T. Katawala).
reactive protein was 7 mg/l with a serum amylase of 53 U/dl. Liver function tests and renal function tests were normal and foetal heart sounds were present. Her booking weight was 61 kg and height 1.65 m with a BMI of 22.4 kg/m2 . Her pregnancy until this point was uneventful with no significant past medical history. She was treated empirically for 24 h with antiemetics, analgesics, intravenous metronidazole and intravenous fluids. On the third day she had increasing abdominal distension, developed pyrexia, and on suspicion of acute appendicitis and perforation a decision for emergency laparotomy was made jointly by surgeons and patient’s obstetrician. She was consented for this procedure considering the risk of foetal loss. She was anaesthetised using a rapid sequence induction technique after pre-oxygenation with 100% oxygen for 3 min with a tight fitting mask. Thiopentone 500 mg, suxamethonium 100 mg with cricoid pressure was used. Direct laryngoscopy was performed and the trachea was intubated with 7.5 mm cuffed endotracheal tube. Anaesthesia was maintained with isoflurane in an air–oxygen mixture 50:50. A nasogastric tube was passed. She remained cardiovascularly stable intra-operatively. Analgesia was achieved by bilateral transversus abdominis plane block with 40 ml of 0.375% levobupivacaine, intravenous paracetamol and morphine, with patient controlled analgesia using morphine for post operative pain relief. A right para-rectal incision was made. The appendix was found to be normal. Complete bowel obstruction at the level of jejunum was found. There was a hernial sac between the root of the mesentery and transverse mesocolon.1 This hernial sac was excised and the defect was repaired. Decompression of the small bowel was
2210-2612/$ – see front matter © 2011 Surgical Associates Ltd. Elsevier Ltd. All rights reserved. doi:10.1016/j.ijscr.2011.01.003
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T. Katawala, E.L. Hamlyn / International Journal of Surgery Case Reports 2 (2011) 51–52
performed without the need for bowel resection. Gravid uterus appeared to be normal. Her operation was uncomplicated and lasted for about 90 min. She had an uneventful recovery and the foetal heart was present in recovery room. She was discharged on the fifth post operative day with a continuing pregnancy. She went into labour at term, had a labour epidural and was delivered by emergency caesarean section for suboptimal cardiotocography. A good sized healthy female baby was born. She had an uneventful postoperative course. 3. Discussion The most common non-obstetric surgical diagnosis in a pregnant woman is appendicitis with a reported incidence of 1:1250–1500; 50% of them happen in second trimester.2 By comparison, small bowel obstruction in the pregnant population is rare (1:17,000).3 Idiopathic transomental herniation is an extremely rare cause of small bowel obstruction, accounting for just 1–4% of all cases of intra-abdominal herniation.4 However, there are a number of case reports of obstruction following previous bariatric surgery in pregnant women. Intra-abdominal small bowel herniation is a recognised complication from bariatric surgery and it may be due to the changes associated with pregnancy that make herniation more likely.5 Incidence of internal hernias after laparoscopic Roux-en-Y gastric bypass [RYGBP] is on a rise, incidence being 3–4.5%. Laparoscopic RYGBP is becoming one of the most commonly performed weight loss surgeries in the USA, especially in females of childbearing age. Weight loss is likely to reduce infertility and increase sexual activity, leading to increase pregnancy rates in such females. The gravid uterus increases intra abdominal pressure and displaces bowel loops superiorly, thereby making them susceptible to entrapment in an internal defect.6 Patients with acute abdomen in pregnancy are diagnostically challenging. The first choice of abdominal imaging in pregnancy is ultrasound. However, complex cases need further imaging. MRI can be safely offered in the 2nd and 3rd trimester of pregnancy when concerns regarding radiofrequency bioeffects in early pregnancy have subsided. MRI gives excellent soft tissue contrast, multiplanar imaging and avoids risks of radiation exposure to the foetus. MRI is a useful confirmatory test for small bowel obstruction in pregnancy. Rapid MRI techniques can show the anatomy and also rule out other pathological processes leading to small bowel obstruction. The image quality can be improved by using rapid pulse sequences.7 The use of intra-operative cardiotocography for foetal monitoring in non-obstetric surgery remains controversial. No hard core evidence exists to validate this. Maintaining maternal cardiovascular and respiratory stability is vital for foetal well being. The effects of general anaesthesia on cardiotocography results in a reduction of beat-to-beat variation with normal baseline frequency. The decreased variability can persist until 90 min in the post operative course due to the residual effects of anaesthetic agents on the foetus. This could be misinterpreted as foetal distress leading to emergency delivery and hence, adding to foetal morbidity and mortality.8
There is often a reluctance to operate on the pregnant patient. Diagnosis is difficult due to non-specific signs and symptoms which are often present in normal pregnancy. Increased steroid levels may suppress any natural inflammatory responses. There should be a low threshold for MRI scanning of the abdomen to establish an early diagnosis and reduce complications from bowel strangulation and sepsis resulting in morbidity and mortality of mother and foetus. In our case an early MRI scan would have been beneficial in allowing earlier surgical intervention. However, even if findings of imaging are unremarkable surgical exploration should not necessarily be delayed as internal hernias can be present with non-specific symptoms.5 It is appreciated that the risks of miscarriage, foetal loss and premature labour are all significantly increased with surgical intervention.9 Coupled with the knowledge that negative laparotomy rates for suspected appendicitis can be as high as 50% in this population,2 the hesitation to operate appears understandable. 4. Conclusion As in the non-pregnant population, prompt diagnosis and early surgical management is the cornerstone for a good outcome when significant pathology is present. Pregnancy should not be a reason to delay surgery. Conflict of interest None declared. Funding None. Ethical approval Written informed consent was obtained from the patient for publication of this case report. References 1. Okino Y, Kiyosue H, Mori H, et al. Root of small bowel mesentery: correlative anatomy and CT features of pathologic conditions. Radiograph 2001;21:90, 1475. 2. Brown JJS, Wilson C, Coleman S, Joypaul BV. Appendicitis in pregnancy: an ongoing diagnostic dilemma. Colorectal Dis 2008;11(2):22–116. 3. Myerson S, Holtz T, Ehrinpreis M, Dhar R. Small bowel obstruction in pregnancy. Am J Gastroenterol 1995;90(2):299–302. 4. Ariyarathenam AV, Tang TY, Nachimuthu S, et al. Transomental defects as a cause of chronic abdominal pain, the role of diagnostic laparoscopy: a case series. Cases J 2009;2:8356. 5. Kakarla N, Dailey C, Marino T, et al. Pregnancy after gastric bypass surgery and internal hernia formation. Obstet Gynecol 2005;105:98, 1195. 6. Ahmed Ahmed R, Malley William O. Internal hernia with Roux Loop Obstruction during pregnancy after gastric bypass surgery. Obes Surg 2006;16:1246–8. 7. McKenna DA, Meehan CP. The use of MRI to demonstrate small bowel obstruction during pregnancy. Br J Radiol 2007;80:e11–4. 8. Immer-Bansi A, Immer FF, Henle S, Spörri S, Petersen-Felix S. Unnecessary emergency caesarean section due to silent C.T.G. during anaesthesia. Br J Anaesth 2001;87:791–3. 9. Mazze RI, Richard I, Kallen B. Appendectomy during pregnancy: a swedish registry study of 778 cases. Obstet Gynecol 1991;77:835–40.
Open Access This article is published Open Access at sciencedirect.com. It is distributed under the IJSCR Supplemental terms and conditions, which permits unrestricted non commercial use, distribution, and reproduction in any medium, provided the original authors and source are credited.
Contents lists available at ScienceDirect
International Journal of Surgery Case Reports journal homepage: www.elsevier.com/locate/ijscr
Case report
Complete small bowel obstruction secondary to transomental herniation in pregnancy Tasneem Katawala ∗ , E.L. Hamlyn Queen Charlotte’s and Chelsea Hospital, Du Cane Road, London, W12 0HS, UK
a r t i c l e
i n f o
Article history: Received 24 January 2011 Accepted 25 January 2011 Available online 1 February 2011 Keywords: Transomental herniation Small bowel obstruction Internal hernia Pregnancy
a b s t r a c t During pregnancy, abdominal pain can be caused by both obstetric and non-obstetric causes. Nonobstetric causes of severe abdominal pain during pregnancy must always be considered. Complete bowel obstruction caused by an internal hernia is rare in obstetric surgical patients. Delays in diagnosis can occur due to non-specific signs and symptoms which can be present in normal pregnancy, and a reluctance to operate on the pregnant patient. Prompt diagnosis and early surgical intervention is the cornerstone for a good outcome. Surgical intervention during pregnancy is associated with increased risk of foetal loss. The use of intra-operative cardiotocography for foetal monitoring in non-obstetric surgery remains controversial. © 2011 Surgical Associates Ltd. Elsevier Ltd. All rights reserved.
1. Introduction Management of the acute abdomen can be challenging in obstetric patients. Physiological and anatomical changes associated with pregnancy make diagnoses extremely difficult, and there are risks to both mother and foetus associated with unnecessary surgical intervention. We report a case of complete small bowel obstruction secondary to transomental herniation of jejunum incidentally found in a pregnant woman with suspected appendicitis and perforation. 2. Case presentation A 37-year-old woman at 20 weeks gestation presented with a one-day history of lower abdominal pain and vomiting. Pain was colicky in nature, radiating to the right iliac fossa. On clinical examination, she was cardiovascularly stable and apyrexial. There was mild distension of her abdomen with rebound tenderness and guarding in the upper right quadrant and epigastrium. Bowel sounds were absent. Fundal height was consistent with 20week gravid uterus and foetal heart sounds were present. Abdominal X-ray showed no air under the diaphragm but dilated loops of bowel. Ultrasound revealed distended loops of bowel with free fluid in the upper abdomen; the appendix could not be seen. Blood tests revealed haemoglobin of 15.3 g/dl, white count of 14.9 × 109 /l, and platelet count of 222 × 109 /l, C-
∗ Corresponding author. E-mail address: [email protected] (T. Katawala).
reactive protein was 7 mg/l with a serum amylase of 53 U/dl. Liver function tests and renal function tests were normal and foetal heart sounds were present. Her booking weight was 61 kg and height 1.65 m with a BMI of 22.4 kg/m2 . Her pregnancy until this point was uneventful with no significant past medical history. She was treated empirically for 24 h with antiemetics, analgesics, intravenous metronidazole and intravenous fluids. On the third day she had increasing abdominal distension, developed pyrexia, and on suspicion of acute appendicitis and perforation a decision for emergency laparotomy was made jointly by surgeons and patient’s obstetrician. She was consented for this procedure considering the risk of foetal loss. She was anaesthetised using a rapid sequence induction technique after pre-oxygenation with 100% oxygen for 3 min with a tight fitting mask. Thiopentone 500 mg, suxamethonium 100 mg with cricoid pressure was used. Direct laryngoscopy was performed and the trachea was intubated with 7.5 mm cuffed endotracheal tube. Anaesthesia was maintained with isoflurane in an air–oxygen mixture 50:50. A nasogastric tube was passed. She remained cardiovascularly stable intra-operatively. Analgesia was achieved by bilateral transversus abdominis plane block with 40 ml of 0.375% levobupivacaine, intravenous paracetamol and morphine, with patient controlled analgesia using morphine for post operative pain relief. A right para-rectal incision was made. The appendix was found to be normal. Complete bowel obstruction at the level of jejunum was found. There was a hernial sac between the root of the mesentery and transverse mesocolon.1 This hernial sac was excised and the defect was repaired. Decompression of the small bowel was
2210-2612/$ – see front matter © 2011 Surgical Associates Ltd. Elsevier Ltd. All rights reserved. doi:10.1016/j.ijscr.2011.01.003
52
T. Katawala, E.L. Hamlyn / International Journal of Surgery Case Reports 2 (2011) 51–52
performed without the need for bowel resection. Gravid uterus appeared to be normal. Her operation was uncomplicated and lasted for about 90 min. She had an uneventful recovery and the foetal heart was present in recovery room. She was discharged on the fifth post operative day with a continuing pregnancy. She went into labour at term, had a labour epidural and was delivered by emergency caesarean section for suboptimal cardiotocography. A good sized healthy female baby was born. She had an uneventful postoperative course. 3. Discussion The most common non-obstetric surgical diagnosis in a pregnant woman is appendicitis with a reported incidence of 1:1250–1500; 50% of them happen in second trimester.2 By comparison, small bowel obstruction in the pregnant population is rare (1:17,000).3 Idiopathic transomental herniation is an extremely rare cause of small bowel obstruction, accounting for just 1–4% of all cases of intra-abdominal herniation.4 However, there are a number of case reports of obstruction following previous bariatric surgery in pregnant women. Intra-abdominal small bowel herniation is a recognised complication from bariatric surgery and it may be due to the changes associated with pregnancy that make herniation more likely.5 Incidence of internal hernias after laparoscopic Roux-en-Y gastric bypass [RYGBP] is on a rise, incidence being 3–4.5%. Laparoscopic RYGBP is becoming one of the most commonly performed weight loss surgeries in the USA, especially in females of childbearing age. Weight loss is likely to reduce infertility and increase sexual activity, leading to increase pregnancy rates in such females. The gravid uterus increases intra abdominal pressure and displaces bowel loops superiorly, thereby making them susceptible to entrapment in an internal defect.6 Patients with acute abdomen in pregnancy are diagnostically challenging. The first choice of abdominal imaging in pregnancy is ultrasound. However, complex cases need further imaging. MRI can be safely offered in the 2nd and 3rd trimester of pregnancy when concerns regarding radiofrequency bioeffects in early pregnancy have subsided. MRI gives excellent soft tissue contrast, multiplanar imaging and avoids risks of radiation exposure to the foetus. MRI is a useful confirmatory test for small bowel obstruction in pregnancy. Rapid MRI techniques can show the anatomy and also rule out other pathological processes leading to small bowel obstruction. The image quality can be improved by using rapid pulse sequences.7 The use of intra-operative cardiotocography for foetal monitoring in non-obstetric surgery remains controversial. No hard core evidence exists to validate this. Maintaining maternal cardiovascular and respiratory stability is vital for foetal well being. The effects of general anaesthesia on cardiotocography results in a reduction of beat-to-beat variation with normal baseline frequency. The decreased variability can persist until 90 min in the post operative course due to the residual effects of anaesthetic agents on the foetus. This could be misinterpreted as foetal distress leading to emergency delivery and hence, adding to foetal morbidity and mortality.8
There is often a reluctance to operate on the pregnant patient. Diagnosis is difficult due to non-specific signs and symptoms which are often present in normal pregnancy. Increased steroid levels may suppress any natural inflammatory responses. There should be a low threshold for MRI scanning of the abdomen to establish an early diagnosis and reduce complications from bowel strangulation and sepsis resulting in morbidity and mortality of mother and foetus. In our case an early MRI scan would have been beneficial in allowing earlier surgical intervention. However, even if findings of imaging are unremarkable surgical exploration should not necessarily be delayed as internal hernias can be present with non-specific symptoms.5 It is appreciated that the risks of miscarriage, foetal loss and premature labour are all significantly increased with surgical intervention.9 Coupled with the knowledge that negative laparotomy rates for suspected appendicitis can be as high as 50% in this population,2 the hesitation to operate appears understandable. 4. Conclusion As in the non-pregnant population, prompt diagnosis and early surgical management is the cornerstone for a good outcome when significant pathology is present. Pregnancy should not be a reason to delay surgery. Conflict of interest None declared. Funding None. Ethical approval Written informed consent was obtained from the patient for publication of this case report. References 1. Okino Y, Kiyosue H, Mori H, et al. Root of small bowel mesentery: correlative anatomy and CT features of pathologic conditions. Radiograph 2001;21:90, 1475. 2. Brown JJS, Wilson C, Coleman S, Joypaul BV. Appendicitis in pregnancy: an ongoing diagnostic dilemma. Colorectal Dis 2008;11(2):22–116. 3. Myerson S, Holtz T, Ehrinpreis M, Dhar R. Small bowel obstruction in pregnancy. Am J Gastroenterol 1995;90(2):299–302. 4. Ariyarathenam AV, Tang TY, Nachimuthu S, et al. Transomental defects as a cause of chronic abdominal pain, the role of diagnostic laparoscopy: a case series. Cases J 2009;2:8356. 5. Kakarla N, Dailey C, Marino T, et al. Pregnancy after gastric bypass surgery and internal hernia formation. Obstet Gynecol 2005;105:98, 1195. 6. Ahmed Ahmed R, Malley William O. Internal hernia with Roux Loop Obstruction during pregnancy after gastric bypass surgery. Obes Surg 2006;16:1246–8. 7. McKenna DA, Meehan CP. The use of MRI to demonstrate small bowel obstruction during pregnancy. Br J Radiol 2007;80:e11–4. 8. Immer-Bansi A, Immer FF, Henle S, Spörri S, Petersen-Felix S. Unnecessary emergency caesarean section due to silent C.T.G. during anaesthesia. Br J Anaesth 2001;87:791–3. 9. Mazze RI, Richard I, Kallen B. Appendectomy during pregnancy: a swedish registry study of 778 cases. Obstet Gynecol 1991;77:835–40.
Open Access This article is published Open Access at sciencedirect.com. It is distributed under the IJSCR Supplemental terms and conditions, which permits unrestricted non commercial use, distribution, and reproduction in any medium, provided the original authors and source are credited.
