HERNIA INTERNA

Paciente do sexo feminino, jovem, com passado de cirurgia bariátrica evoluindo com dor abdominal.
Obs: Para visualizar as fotos ampliadas, clique em cima da imagem desejada.

Tomografia, plano axial, ao nível do mesogástrio, observando-se adensamento da gordura abdominal mesentérica com questionável ectasia dos vasos mesentéricos.

Tomografia, plano axial, onde observamos o sinal do "redemoinho" dos vasos mesentéricos, observe o feitio espiralar dos vasos. A hérnia interna observada neste exame determinou repuxamento das estruturas mesentéricas. A veia mesentérica estava torcida no eixo longitudinal. Este achado determina ectasia dos segmentos venosos distais e consequente congestão venosa. Daí o adensamento da gordura mesentérica.

A seta amarela mostra as suturas metálicas do gastroplastia.

Na próxima figura, tentamos demonstrar a torção da veia mesentérica superior em seu próprio eixo.

Demonstramos 4 cortes axiais sequenciais de cima para baixo. A seta amarela mostra a artéria mesentérica superior e a seta azul a veia mesentérica superior. Observe que a veia mesentérica apresenta redução abrupta do calibre contornando a artéria mesentérica superior.

Plano coronal, MIP. Nesta reconstrução da fase portal (venosa), observamos o "STOP" do segmento proximal da veia mesentérica superior, justamente o ponto de torção sobre seu eixo. A seta verde mostra a porção proximal e a azul a distal da veia mesentérica superior.

Parabéns a Dra. Sandra Cendon pelo excelente diagnóstico.

Ok, ok, ok, não é tão fácil assim entender o que aconteceu com os vasos mesentéricos, então segue um artigo bem legal sobre o tema. Abraço a todos!

http://www.ajronline.org/cgi/content/full/188/3/745

Internal Hernia After Gastric Bypass: Sensitivity and Specificity of Seven CT Signs with Surgical Correlation and Controls

Mark E. Lockhart¹, Franklin N. Tessler¹, Cheri L. Canon¹, J. Kevin Smith¹, Matthew C. Larrison¹, Naomi S. Fineberg², Brandon P. Roy^3,4 and Ronald H. Clements³

¹ Department of Radiology, University of Alabama at Birmingham, 619 19th St. S, Birmingham, AL 35249-6830.

² Department of Biostatistics, University of Alabama at Birmingham, Birmingham, AL 35294-0022.
³ Department of Surgery, University of Alabama at Birmingham, Birmingham, AL 35249-0016.
⁴ Present address: Department of Surgery, WakeMed Hospital, Raleigh, NC 27610.

OBJECTIVE. The purpose of this study was to evaluate the sensitivity and specificity of seven CT signs in the diagnosis of internal hernia after laparoscopic Roux-en-Y gastric bypass.

MATERIALS AND METHODS. With institutional review board approval, the CT scans of 18 patients (17 women, one man) with surgically proven internal hernia after laparoscopic Roux-en-Y gastric bypass were retrieved, as were CT studies of a control group of 18 women who had undergone gastric bypass but did not have internal hernia at reoperation. The scans were reviewed by three radiologists for the presence of seven CT signs of internal hernia: swirled appearance of mesenteric fat or vessels, mushroom shape of hernia, tubular distal mesenteric fat surrounded by bowel loops, small-bowel obstruction, clustered loops of small bowel, small bowel other than duodenum posterior to the superior mesenteric artery, and right-sided location of the distal jejunal anastomosis. Sensitivity and specificity were calculated for each sign. Stepwise logistic regression was performed to ascertain an independent set of variables predictive of the presence of internal hernia.

RESULTS. Mesenteric swirl was the best single predictor of hernia; sensitivity was 61%, 78%, and 83%, and specificity was 94%, 89%, and 67% for the three reviewers. The combination of swirled mesentery and mushroom shape of the mesentery was better than swirled mesentery alone, sensitivity being 78%, 83%, and 83%, and specificity being 83%, 89%, and 67%, but the difference was not statistically significant.

CONCLUSION. Mesenteric swirl is the best indicator of internal hernia after laparoscopic Roux-en-Y gastric bypass, and even minor degrees of swirl should be considered suspicious.

Keywords: CT • gastrointestinal radiology • hernia • small bowel