Internal herniation is a rare complication and has low incidence of less than 1%. We present a case of intestinal obstruction due to small bowel entrapment in preperitoneal space secondary to previous laparotomy for ruptured left tubal pregnancy.
A 38-year-old Chinese lady presented to Emergency Department (ED) at day 9 post laparotomy for ruptured left tubal pregnancy. During the first presentation, she complained of mild abdominal pain without vomiting. She was discharged with analgesia without doing abdominal Xray. She returned to ED five days later with persistent abdominal pain and symptom of intestinal obstruction. An abdominal X-ray revealed dilated stomach and small bowel. Patient was admitted and underwent laparotomy. Intraoperatively, the stomach and small bowel were distended and tense with segment of small bowel 30 cm from terminal ileum was entrapped in a potential space at the preperitoneal region secondary to previous surgery. Post operatively, patient was admitted to ICU for ventilatory support and extubated at day 5 post operation. She developed severe gastropharesis and required total parenteral nutrition.
CT scan is a better imaging modality for evaluation of abdominal pain, but the patient was not subjected for to one because her condition deteriorated and proceeded for laparotomy. Intraoperatively, there was an internal herniation leading to a mechanical obstruction and required decompression by performing enterotomy at mid jejunum. This complication is very rare and less than 1 % incidence. Post operation, patient developed severe gastropharesis that resolved after resting the bowel by keeping nil by mouth and total parenteral nutrition.
Numerous studies have demonstrated low sensitivity for plain abdominal radiography in the evaluation of acute abdominal pain, but it is still the method of choice in ED for cases of suspected obstruction, perforation or foreign body especially in post operation patient.