Ahmed Hamimi Abdullah Hamimi MD, PhD, Presenter: Nothing to Disclose

Trying to define the most valuable radiological sign (s) for the diagnosis of internal hernias and their mimics; mainly cocoon syndrome and adhesions.

In a period of 32 consecutive months; a total of 240 patients were admitted with abdominal pain with signs of remittent or persistent intestinal obstruction. Among those patients; 180 cases had history of previous abdominal operative intervention. All cases are subjected to multislice CT examination of the abdomen and pelvis using IV contrast and positive oral water soluble contrast 30 minutes prior to examination. The examination is done in single porto-venous phase. Thirteen cases were definitely diagnosed by laparoscopy as internal hernias. The cases radiological profiles were revised in retrograde manner. The radiological diagnosis of possible internal hernia was wrong in three other cases. Two cases were finally diagnosed as cocoon syndrome.

The age of the patients varies between 22 and 63 years with average age of 36 +/- 2.3 years. Most of the patients were females with ratio of 2:1. The radiological signs used for the radiological diagnosis were: Swirl sign Local bowel gathering Bowel dilatation Abnormal position of the duodenojejunal junction Bowel other than duodenum posterior to the superior mesenteric artery. Distal jejunal anastomosis located to the right side Mushroom appearance No single sign alone was efficient and consistent in the diagnosis of internal hernia. Swirl sign, local bowel gathering and bowel dilatation were found to be the best combination for diagnosis of internal hernia. There were no definite sign to differentiate between cocoon syndrome and internal hernia. Both cases have been operated and diagnosis was made intra-operatively.

A single sign is not enough for the diagnosis of internal hernia. I suggest a combination of Swirl sign, local bowel gathering and bowel dilatation in appropriate clinical settings for diagnosis of internal hernia. Still disease like cocoon syndrome will remain difficult to diagnosis in radiology

The prevalence of internal hernia is increasing due to increased rate of operative abdominal intervention. Prompt radiological diagnosis is crucial to avoid unwanted surgery in a non-virgin abdomen.

Hamimi, A, Internal Hernias and Their Mimics: How Would Radiologists Help?.  Radiological Society of North America 2013 Scientific Assembly and Annual Meeting, December 1 - December 6, 2013 ,Chicago IL. http://archive.rsna.org/2013/13019972.html