Paraduodenal hernia is a protrusion of the intra-abdominal organs into the duodenum-jejunum recess (Treitz pocket). The disease is manifested by periodic abdominal pain a few hours after eating, giving to the lower back, spine and epigastric region; belching, nausea and vomiting, constipation. Unpleasant sensations are intensified in an upright position. Diagnosis is based on the clinical picture, the history of life and disease, intestinal radiography with barium and CT of the abdominal cavity. The treatment is operative. The intervention consists in releasing the organs located in the hernial sac and suturing the hernial gate.
Meaning
Paraduodenal hernia (Treitz hernia, okolodvenadtsatiperstnaya) is an internal hernia of the abdomen, which is formed when the internal organs (more often the loops of the small intestine) bulge into the duodenal-jejunal pocket. The disease is named after the Austrian pathologist Wenzel Treitz, who described in detail in the middle of the XIX century the anatomical location and symptoms of pathological protrusion. The prevalence of the disease is 30-40% of all cases of internal abdominal hernias. Paraduodenal hernia develops mainly at the age of 20-40 years. More often affects males. Due to the difficulties of recognition, most hernias are diagnosed intraoperatively.
Causes of paraduodenal hernia
The main predisposing factors of the perinatal duodenal hernia are intrauterine abnormalities of the development of the digestive organs. The disease can manifest itself as a result of connective tissue dysplasia, incomplete bowel rotation and the associated deviation in the formation of the Treitz pocket. In adulthood, the cause of hernia can be independent and postoperative perivisceritis, adhesive intestinal disease, as a result of which there is a displacement of intra-abdominal organs. Abdominal operations (liver transplantation, gastric bypass surgery, intestinal resection) can lead to dislocation of the intestine and other anatomical structures of the abdomen.
Pathogenesis
The Treitz pocket is formed on the anterior surface of the posterior abdominal wall, to the left of the 2nd lumbar vertebra in the area of the transition of the 12th duodenum to the jejunum. The fossa, bounded by the duodenal-junal bend of the small intestine and the peritoneal fold, forms a hernial gate of pathological bulging, having an oval or slit-shaped shape. The bottom of the pocket is represented by the parietal peritoneum, part of which, when a paraduodenal hernia occurs, prolapses into retroperitoneal tissue, forming a hernial sac. The hernial sac is located posteriorly from the pancreas and can spread to the spleen. The hernial contents are mainly represented by loops of the small intestine.
Classification
Paraduodenal hernias can be congenital and acquired, uncomplicated and impaired, have a large and small size. Depending on the location relative to the vertebral column in modern herniology, there are two types of hernial protrusions:
- Left-sided hernia. It occurs in 70-75% of cases, located to the left of the Treitz ligament behind the stomach.
- Right-sided hernia. It is located to the right of the spine, below the transverse colon. The right-sided paraduodenal hernia is characterized by a displacement of the duodenum to the right, the jejunum to the right and posteriorly.
Symptoms of paraduodenal hernia
The clinical picture of the disease is variable, it depends on the volume and localization of the hernia. With small sizes of pathological protrusion, the symptoms of the disease may be absent. As the hernial sac increases, periodic cramping pains occur in the right or left half of the abdomen, radiating into the spine, lower back or epigastric region. Unpleasant sensations develop 2-3 hours after eating or against the background of physical activity.
The pain increases in the standing and sitting position and weakens in a horizontal position on the side opposite to the localization of the hernia. Patients complain of belching, flatulence, nausea and vomiting (rarely). These symptoms do not last long and are most often stopped by themselves when changing the position of the body. There are prolonged constipation: stool delays can be 5-7 days.
Complications
The appearance of sharp paroxysmal abdominal pain, persistent constipation, vomiting indicates infringement of the paraduodenal hernia. When palpating the abdominal wall above the navel, a soft elastic formation is determined, which shifts slightly during breathing. As a result of infringement of the intestine, acute small intestinal obstruction occurs. Prolonged compression leads first to ischemia, and then to necrosis of part of the intestine. The absence of emergency measures entails the development of peritonitis and sepsis.
Diagnostics
Due to the fact that paraduodenal hernia in most cases is not visually and palpationally determined, there is no specific symptomatology of the disease, diagnosis of paraduodenal hernia causes difficulties. To establish a diagnosis, it is necessary to undergo the following examinations:
- Examination by a surgeon. During visual examination, there is no hernial bulge of the anterior abdominal wall, with palpation of the abdomen, only large paraduodenal hernias can be felt. Therefore, additional studies are required for a more accurate diagnosis.
- X-ray examination. Radiography of the passage of barium through the small intestine helps to see intestinal obstruction and enlarged segments of the small intestine located in the Treitz pocket. With a paraduodenal hernia, there is a shift of the duodenum 12 to the right, the jejunum – laterally and posteriorly. Before the study, it is necessary to exclude perforation of the intestine.
- CT of the abdominal cavity. Allows you to better visualize the gastrointestinal tract, the hernial sac with its contents.
Differential diagnosis is carried out with peptic ulcer, benign or malignant neoplasms of the duodenum 12. Periodic acute abdominal pain can be mistaken for exacerbation of pancreatitis, cholecystitis. In this case, instrumental research methods help to make the correct diagnosis.
Treatment for paraduodenal hernia
Treatment of paraduodenal hernia is surgical. When confirming the diagnosis, an upper median laparotomy is performed. The hernial gates are dissected, the organs are released from the hernial sac. Then the slit-like defect is sutured and the abdominal cavity is revised. With a strangulated hernia, the hernial sac is removed with a part of the necrotic intestine, after which the hernial gate is sutured. In the postoperative period, a course of antibiotic therapy is prescribed. In the presence of complications, detoxification and anti-inflammatory therapy are prescribed.
Prognosis and prevention
The prognosis of the disease depends on a well-conducted differential diagnosis. With the timely detection of a paraduodenal hernia and the operation, the prognosis is favorable. Infringement of pathological hernial protrusion causes a number of serious, life-threatening complications. Prevention is aimed at early diagnosis of hernia. It is recommended that when the first symptoms of the disease appear, contact a gastroenterologist or abdominal surgeon for additional diagnostic studies.