PC3068: Don’t Get It Twisted: A Case of Strangulated Hernia in an Otherwise Healthy Child

Introduction: Mesentery is a fold of membrane that suspends the intestine from the posterior abdominal wall. It provides physical support of as well as neurovascular and lymphatic supply to the intestines. A malfunction of mesentery can lead to significant complications including bowel necrosis, malformation, ileus, and decreased nutrient absorption.

Case Description: This is a 2-year-old previously healthy girl with a one-day history of abdominal pain and vomiting. Her initial symptom was abdominal discomfort and unrelenting non-bloody/non-bilious emesis that eventually progressed to darker, coffee-ground emesis. Upon initial presentation to the ER, she was febrile and lethargic, but arousable. Her physical exam findings were significant for an firm and diffusely tender abdomen. An emergent CT revealed a bowel obstruction and moderate amount of free fluid in the abdomen. An emergent diagnostic laparoscopy was initiated and was swiftly converted to a laparotomy once necrotic tissue was visualized throughout the abdomen. Following laparotomy, a 25 cm segment of ileum was seen to be completely necrotic with another distal segment of ileum that appeared slightly ischemic. The distal segment was successfully re-vascularized with a warm saline bath and did not require excision, however the necrotic ileum tissue required resection with end-to-end anastomosis of the small intestine. On further inspection there was absence of mesentery on the distal ¾ of the small intestine. There was an obvious internal hernia causing the patient’s obstruction and ischemia. Following the operating room, the patient was closely monitored in the PICU for 6 days. She was initially NPO with TPN with an NG tube. NG was initially set to LIS and then transitioned to gravity on POD 3 and finally removed on POD 4. After removal of her NG tube, her diet was slowly advanced over two days and she was discharged home POD 6. Upon outpatient follow-up with pediatric surgery, the patient was at baseline health with normal oral intake and had made full recovery.

Discussion: Herniation due to absence of mesentery accounts for 0.2-0.9% of small bowel obstructions. There are only 13 documented cases in the pediatric population. In our patient, the absence of mesentery resulted in the strangulation of 25 cm of small bowel secondary to an internal hernia. This case illustrates the vital role of the general pediatricians and ER physicians in recognizing serious symptoms, as reported by parents, and recommending urgent emergency room and surgical evaluation. Immediate intervention at first sign of concern can mitigate severe morbidities.

Conclusion: This case shows a unique congenital abnormality and its potentially life-threatening complication. It further reinforces the importance of emergent evaluation and treatment of pediatric patients presenting to the emergency room.