AJR:186, March 2006 703

AJR 2006; 186:703717

0361803X/06/1863703
American Roentgen Ray Society
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Martin et al.
Radiographic and Clinical
Findings of Hernias
Gas t roi nt es t i nal I magi ng Revi ew
Review of Internal Hernias:
Radiographic and Clinical Findings
Lucie C. Martin
1
Elmar M. Merkle
William M. Thompson
Martin LC, Merkle EM, Thompson WM
Keywords: colon, CT, gastrointestinal radiology, hernia,
small bowel
DOI:10.2214/AJR.05.0644
Received April 14, 2005; accepted after revision
August 9, 2005.
1
All authors: Department of Radiology, Duke University
Medical Center, Box 3808, Durham, NC 27710. Address
correspondence to W. M. Thompson
(thomp132@mc.duke.edu).
OBJECTIVE. Internal hernias, including paraduodenal (traditionally the most common),
pericecal, foramen of Winslow, and intersigmoid hernias, account for approximately 0.55.8%
of all cases of intestinal obstruction and are associated with a high mortality rate, exceeding
50% in some series. To complicate matters, the incidence of internal hernias is increasing be-
cause of a number of relatively new surgical procedures now being performed, including liver
transplantation and gastric bypass surgery. A significant increase in hernias is occurring in pa-
tients undergoing transmesenteric, transmesocolic, and retroanastomotic surgical procedures.
It is important for radiologists to be familiar with and to understand the various types of internal
hernias and their imaging features so that prompt and accurate diagnosis of these conditions
can be made.
CONCLUSION. This article illustrates the imaging findings of internal hernias, with em-
phasis placed on the CT findings, especially in transmesenteric, transmesocolic, and retroanas-
tomotic types of internal hernias.
lthough internal hernias have an
overall incidence of less than
1%, they constitute up to 5.8% of
all small-bowel obstructions,
which, if left untreated, have been reported
to have an overall mortality exceeding 50%
if strangulation is present [1, 2]. Over the
past decade, their incidence has been in-
creasing because of the more frequent per-
formance of liver transplantations and gas-
tric bypass surgery for bariatric treatment.
In this subset of patients, internal hernias
account for just over half of all cases of
small-bowel obstruction, almost equal to
those caused by adhesions in one study [3,
4]. Without a heightened awareness and un-
derstanding of these hernias, they can often
be misdiagnosed, with subsequent signifi-
cant morbidity and mortality. The purpose
of this article is therefore not only to review
the definition and types of internal hernias,
but also to describe the clinical and radio-
graphic findings, with an emphasis placed
on the CT features, because CT is rapidly
becoming the first-line imaging technique
in these patients.
Definition
Hernias are of two main types, external and
internal [1]. External hernias refer to prolapse
of intestinal loops through a defect in the wall
of the abdomen or pelvis, and internal hernias
are defined by the protrusion of a viscus
through a normal or abnormal peritoneal or
mesenteric aperture within the confines of the
peritoneal cavity. The orifice can be either ac-
quired, such as a postsurgical, traumatic, or
postinflammatory defect, or congenital, in-
cluding both normal apertures, such as the fo-
ramen of Winslow, and abnormal apertures
arising from anomalies of internal rotation
and peritoneal attachment.
In the broad category of internal hernias
are several main types, as traditionally de-
scribed by Meyers [5], based on location.
Specifically, using historical data, these
consist of paraduodenal (53%), pericecal
(13%), foramen of Winslow (8%), trans-
mesenteric and transmesocolic (8%), inter-
sigmoid (6%), and retroanastomotic (5%)
(Fig. 1), with the overall incidence of inter-
nal hernias being 0.20.9%. The other 7%
described by Meyers included paravesical
hernias, which are not true internal hernias
and thus are not described in this article. In
general, internal hernias have no age or sex
predilection. With more new surgical proce-
dures being performed using a Roux loop,
the number of transmesenteric, transmeso-
colic, and retroanastomotic internal hernias
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Martin et al.
704 AJR:186, March 2006
has been increasing. These are probably
more common than the traditional incidence
of the various types of internal hernias re-
ported by Meyers (Table 1).
General Clinical Findings
Clinically, internal hernias can be asymp-
tomatic or cause significant discomfort
ranging from constant vague epigastric pain
to intermittent colicky periumbilical pain
[1, 5] (Table 1). Additional symptoms in-
clude nausea, vomiting (especially after a
large meal), and recurrent intestinal ob-
struction [1, 2, 57]. Symptom severity re-
lates to the duration and reducibility of the
hernia and the presence or absence of incar-
ceration and strangulation [6]. These symp-
toms may be altered or relieved by changes
in patient position [5, 7]. Because of the pro-
pensity of these hernias to spontaneously re-
duce, patients are best imaged when they are
symptomatic [5, 7].
General Imaging Findings on
Radiography and CT
Imaging studies often play an important
role in the diagnosis of internal hernias be-
cause they are often difficult to identify clini-
cally. In the past, these hernias were most fre-
quently assessed with small-bowel oral
contrast studies. However, CT has become the
first-line imaging technique in these patients
because of its availability, speed, and multi-
planar reformatting capabilities. General ra-
diographic features with barium studies in-
clude apparent encapsulation of distended
bowel loops with an abnormal location, ar-
rangement or crowding of small-bowel loops
within the hernial sac, evidence of obstruction
with segmental dilatation and stasis, with ad-
ditional features of apparent fixation and re-
versed peristalsis during fluoroscopic evalua-
tion [1, 5] (Table 1). On CT, additional
findings include mesenteric vessel abnormal-
ities, with engorgement, crowding, twisting,
and stretching of these vessels commonly
found and providing an important clue to the
underlying diagnosis [6].
Paraduodenal Hernias
In the classic older literature, paraduode-
nal hernias were the most common type of
internal hernia, accounting for approxi-
mately 53% of all cases [1]. Unlike most
types of internal hernias, this subtype does
have a sex predilection, being found more
Fig. 1Diagrammatic
illustration shows
various types of internal
hernias:
A = paraduodenal,
B = foramen of Winslow,
C = intersigmoid,
D = pericecal,
E = transmesenteric, and
F = retroanastomotic.
commonly in men by a ratio of 3:1 [1, 2, 6].
There are two main types, left and right,
with the former consisting of most (75%)
cases [1, 68].
Left Paraduodenal Hernia
Left paraduodenal hernias have an overall
incidence of approximately 40% of all inter-
nal hernias. They occur when bowel pro-
lapses through Landzerts fossa, an aperture
present in approximately 2% of the popula-
tion (Fig. 1). These hernias therefore can be
classified as a congenital type, normal aper-
ture subtype. Landzerts fossa is located be-
hind the ascending or fourth part of the
duodenum and is formed by the lifting up of
a peritoneal fold by the inferior mesenteric
vein and ascending left colic artery as they
run along the lateral side of the fossa. Small-
bowel loops prolapse posteroinferiorly
through the fossa to the left of the fourth
part of the duodenum into the left portion of
the transverse mesocolon and descending
mesocolon (Fig. 2).
Clinically, in addition to the aforemen-
tioned symptomatology, these patients will
also often present with postprandial pain, typ-
ically chronic in nature, with symptoms dat-
ing back to childhood [5].
On radiography or oral contrast studies,
these hernias will present as an encapsulated
circumscribed mass of a few loops of small
bowel (usually jejunal) in the left upper
quadrant, lateral to the ascending duodenum
[1, 5, 9] (Fig. 3A). These loops may have
mass effect, depressing the distal transverse
colon and indenting the posterior wall of the
stomach [1, 5] (Figs. 3B and 3C). Mild
duodenal dilatation often occurs, and the ef-
ferent loop often shows an abrupt caliber
change [5]. With CT, similar findings of en-
capsulated bowel loops are noted, either at
the duodenojejunal junction between the
stomach and pancreas to the left of the liga-
ment of Treitz; behind the pancreatic tail it-
self, displacing the inferior mesenteric vein
to the left; or between the transverse colon
and the left adrenal gland [57, 912]
(Figs. 4A4D). Evidence of small-bowel ob-
struction with dilated loops and airfluid
levels is also commonly seen [5] (Fig. 4E).
There is associated mass effect with dis-
placement of the posterior stomach wall an-
teriorly, the duodenojejunal junction infero-
medially, and the transverse colon inferiorly
[6, 7, 10]. Mesenteric vessel abnormalities,
including enlargement, stretching, and ante-
rior displacement of the main mesenteric
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TABLE 1: Clinical and Imaging Findings for Internal Hernias
Hernia Type Subtype Incidence
a
Characteristic
Clinical Findings
Radiography and Barium
Studies CT Findings Key Vessel
Left paraduodenal Congenital, normal
aperture
40% of all hernias,
75% of
paraduodenal
hernias
Postprandial pain, may date
back to childhood
Encapsulated cluster of
jejunum in LUQ, lateral to the
ascending duodenum; may
have mass effect indenting
posterior wall of stomach or
displacing transverse colon
inferiorly
Clustered dilated small-bowel
loops between stomach and
pancreas, behind pancreas
itself, or between transverse
colon and left adrenal gland
IMV in neck of hernial sac with
anterior and upward
displacement of IMV
Right paraduodenal Congenital, normal
aperture
13% of all hernias,
25% of
paraduodenal
hernias
Postprandial pain, may date
back to childhood
Encapsulated loops lateral
and inferior to the
descending duodenum;
associated with small-bowel
nonrotation
Encapsulated loops lateral
and inferior to the
descending duodenum;
associated with small-bowel
nonrotation
SMA displaced anteriorly
Pericecal Congenital or acquired,
abnormal aperture
13% RLQ pain, differential
diagnosis of appendicitis;
high incidence of occlusive
symptoms
Clustered small-bowel loops
(usually distal) posterior and
lateral to the cecum in right
paracolic gutter
Clustered small-bowel loops
(usually distal) posterior and
lateral to the cecum in right
paracolic gutter
None
Foramen of Winslow Congenital, normal
aperture
8% Symptoms of proximal
obstruction because of mass
effect on stomach; symptom
onset often preceded by
changes in intraabdominal
pressure (i.e., parturition,
straining); relief of symptoms
with forward bending
Circumscribed loops medial
and posterior to the stomach;
differential diagnosis of cecal
volvulus
Loops in lesser sac between
liver hilum and IVC
None; vessels stretched
through foramen of Winslow
Intersigmoid Type 1: congenital,
normal aperture; types 2
and 3: acquired,
abnormal aperture
6% None U- or C-shaped cluster of
small bowel posterior and
lateral to the sigmoid colon
U- or C-shaped cluster of
small bowel posterior and
lateral to the sigmoid colon
None
Transmesenteric
b
In children: congenital,
abnormal aperture; in
adults: usually acquired,
abnormal aperture
8% Two typical patient
populations: children and
postsurgical adults; in adults,
less vomiting because fewer
secretions in proximal gastric
pouch, onset more acute
Variable, air within gastric
remnant; may simulate a left
paraduodenal hernia
Small bowel lateral to colon;
displaced omental fat with
small bowel directly abutting
abdominal wall
None
Retroanastomotic
b
Acquired, abnormal
aperture
5% Usually within the first
postoperative month; less
vomiting because fewer
secretions in the proximal
gastric pouch
Variable Variable None
NoteLUQ = left upper quadrant, IMV = inferior mesenteric vein, SMA = superior mesenteric artery, RLQ = right lower quadrant, IVC = inferior vena cava.
a
Incidence for first six types from Meyers [5], which are historic data but only major source currently available. Incidence for these first six types of internal hernias totals only 93% because perivesical hernias reported
[5] are not true internal hernias, so they were not included in this review.
b
Probably more transmesenteric and retroanastomotic internal hernias currently because of number of liver transplant and gastric bypass operations being performed throughout the United States during past decade.
The 5% refers to the incidence after Roux loops used during surgery for reasons other than liver transplantation or gastric bypass.
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Martin et al.
706 AJR:186, March 2006
Fig. 2Graphic
illustration of a left
paraduodenal hernia
depicts loop of small
bowel prolapsing
(curved arrow) through
Landzerts fossa, located
behind inferior
mesenteric vein and
ascending left colic
artery (straight arrow).
Herniated bowel loops
are therefore located
lateral to fourth portion of
duodenum.
trunks, especially the inferior mesenteric
vein, to the left, are also helpful findings [10,
11]. If the vasculature is optimally visual-
ized, one can often see additional findings of
engorged vessels grouped together at the en-
trance of the hernia sac, with the proximal
jejunal arteries showing an abrupt change of
direction posteriorly behind the inferior me-
senteric artery [6, 7] (Fig. 4F). The inferior
mesenteric vein and ascending left colic ar-
tery lie in the anterior and medial border of
the left paraduodenal hernia and may be dis-
placed laterally (Figs. 2 and 4C).
Right Paraduodenal Hernia
Right paraduodenal hernias have an over-
all incidence of approximately 13% and
occur when bowel herniates through
Waldeyers fossa (representing a defect in
the first part of the jejunal mesentery), be-
hind the superior mesenteric artery and in-
ferior to the transverse or third portion of the
duodenum (Fig. 5). This normal yet uncom-
mon recess is found in less than 1% of the
population and, like left paraduodenal her-
nias, the right paraduodenal hernia can be
classified as congenital type, normal aper-
ture subtype [1, 9]. In these situations, the
herniated contents are located in the right
half of the transverse mesocolon and behind
the ascending mesocolon. This type of her-
nia occurs more frequently in the setting of
nonrotated small bowel [6, 8]. When com-
pared with the left paraduodenal hernias,
those on the right are usually larger and are
more often fixed [5].
Clinically, these hernias present in a simi-
lar manner to the left paraduodenal hernias
with chronic postprandial pain [5].
On a standard barium gastrointestinal ex-
amination, a larger and more fixed, encap-
sulated, ovoid collection of bowel loops is
noted lateral and inferior to the descending
duodenum, in the right half of the transverse
mesocolon, or behind the ascending meso-
colon [1, 5, 9] (Fig. 6A). As opposed to the
left paraduodenal hernias, both the afferent
and efferent loops of bowel are closely op-
posed and narrowed [1, 5]. With CT, an en-
capsulated cluster of small-bowel loops is
noted in the right mid abdomen, with loop-
ing of the small bowel around the superior
mesenteric artery and vein at the root of the
small-bowel mesentery being seen occa-
sionally [5, 8] (Fig. 6B). Small-bowel ob-
struction may be present with dilated loops
containing airfluid levels. Because right-
sided paraduodenal hernias are thought to
be congenital, related to abnormalities of
embryologic midgut rotation, there may be
additional clues such as small-bowel nonro-
tation, as evidenced by the superior mesen-
teric vein occupying a more ventral and left-
ward position and the absence of a normal
horizontal duodenum [5, 8, 9]. The cecum,
however, remains in its normal position.
Vascular findings include jejunal branches
of the superior mesenteric artery and supe-
rior mesenteric vein looping posteriorly and
to the right of the parent vessel to supply the
herniated loops [1, 5, 8, 9]. Additional vas-
cular findings include the presence of the
superior mesenteric artery, ileocolic artery,
and right colic vein in the anterior margin of
the neck of the hernial sac, displaced anteri-
orly if there is sufficient mass effect by the
encased small-bowel loops [8]. Again, ves-
sel engorgement may also be present and
provide a clue to the diagnosis.
Pericecal Hernias
Historically, pericecal hernias account for
13% of all internal hernias. The pericecal fossa
is located behind the cecum and ascending co-
lon and is limited by the parietocecal fold out-
ward and the mesentericocecal fold inward [9].
Although there are actually four subtypes (ile-
ocolic, retrocecal, ileocecal, and paracecal) of
pericecal hernias, most commonly the herni-
ated loop consists of an ileal segment protrud-
ing through a defect in the cecal mesentery and
extending into the right paracolic gutter [1, 9]
(Fig. 7). These hernias can therefore be subcat-
egorized as either acquired or congenital de-
fects in the cecal mesentery.
Clinically, patients with pericecal hernias
present in a similar manner to those with all
other types of internal hernias except for the
location of symptoms, which tends to be in
the right lower quadrant, so that pericecal
hernias are sometimes mistaken for appen-
diceal abnormalities [1, 9]. A higher inci-
dence of occlusive symptoms with rapid pro-
gression to strangulation is also commonly
found, with a mortality rate reported to be as
high as 75% [9, 13].
Imaging studies, including both barium
and CT, show similar findings. These hernias
can often be confidently diagnosed as a clus-
ter of bowel loops (usually ileal) located
posteriorly and laterally to the normal
cecum, occasionally extending into the right
paracolic gutter [1, 9] (Fig. 8). Again, there
will be evidence of small-bowel obstruction
and mass effect displacing the cecum anteri-
orly and medially.
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Radiographic and Clinical Findings of Hernias
AJR:186, March 2006 707
A B
C
Fig. 3Left paraduodenal hernias shown on upper gastrointestinal series, and
barium enema in one patient and lateral view of upper gastrointestinal series from
different patients.
A, 55-year-old man with gastrointestinal bleeding. Anteroposterior projection of oral
contrast small-bowel study shows cluster of small-bowel loops in left upper
quadrant, lateral to fourth portion of duodenum (arrow).
B, Barium enema study (anteroposterior projection) from same patient as in A
depicts inferior displacement of distal transverse colon and splenic flexure (arrow)
caused by mass in left upper quadrant that was later revealed to be left
paraduodenal hernia.
C, Lateral radiograph from upper gastrointestinal series in 35-year-old woman with
abdominal pain shows small-bowel loops (arrow) causing mass effect and
indentation on posterior aspect of stomach (S), displacing it anteriorly.
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Martin et al.
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Foramen of Winslow
The foramen of Winslow is a normal com-
munication between the greater and lesser
peritoneal cavities, located beneath the free
edge of the lesser omentum, the hepa-
toduodenal ligament (Fig. 9). The posterior,
superior, and inferior boundaries of this fo-
ramen include the inferior vena cava, cau-
date lobe, and duodenum, respectively [14].
This hernia can therefore be subcategorized
as a congenital type, normal aperture sub-
type. It constitutes 8% of all internal hernias,
A B
C D
Fig. 4CT scans from six patients with left paraduodenal hernia.
A, Axial contrast-enhanced CT scan in 11-year-old boy shows small-bowel loops (arrows) between stomach (S) and pancreas (P).
B, Axial contrast-enhanced CT scan in 28-year-old man shows small-bowel loops (white arrow) behind pancreas (P) itself. Black arrow indicates stomach.
C, Axial contrast-enhanced CT scan in 36-year-old man shows small-bowel loops (arrows) displaying inferior mesenteric vein (arrowhead) to left.
D, Coronal reconstruction of contrast-enhanced CT data set in 28-year-old man shows small-bowel loops between transverse colon (T) and left adrenal gland (arrow).
(Fig. 4 continues on next page)
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Radiographic and Clinical Findings of Hernias
AJR:186, March 2006 709
E F
Fig. 4 (continued)CT scans from six patients with left paraduodenal hernia.
E, Unenhanced axial CT scan in 35-year-old man shows evidence of small-bowel obstruction of herniated contents as multiple loops of dilated small bowel (arrow) with
fluidfluid levels noted.
F, Axial contrast-enhanced CT scan in 23-year-old man shows multiple engorged and prominent vessels (arrow) in herniated sac caused by vascular congestion and
obstruction.
with approximately two thirds containing
small bowel alone, and the remaining one
third containing additional cecum and as-
cending colon and occasionally gallbladder,
transverse colon, and omentum [1, 5, 6, 9,
14]. Risk factors for this type of hernia in-
clude an enlarged foramen of Winslow, an
abnormally long small-bowel mesentery,
persistence of the ascending mesocolon al-
lowing marked mobility of bowel, and an
Fig. 5Graphic
illustration of right
paraduodenal hernia
shows loop of small
bowel prolapsing
(curved arrow) through
Waldeyers fossa, behind
superior mesenteric
artery (straight arrow)
and inferior to third
portion of duodenum
(asterisk).
elongated right hepatic lobe (such as a
Riedels lobe), which is thought to direct the
mobile intestinal loops toward the foramen
of Winslow [1, 5, 6, 9, 14, 15].
The typical patient is middle-aged, with
acute onset of severe, progressive pain and
signs of small-bowel obstruction [1]. Patients
also often present with symptoms of a proxi-
mal bowel obstruction, which are caused by a
pressure effect on the stomach by the herni-
ated contents [14]. Symptom onset is often
preceded by a change in intraabdominal pres-
sure, such as parturition or straining [1, 5].
Occasionally, forward bending provides some
relief [1]. Rarely, patients will present with
jaundice or a distended gallbladder, again
from pressure or stretching of the common
bile duct by the herniated colon [5].
When the small bowel herniates, conven-
tional radiographs may reveal a circum-
scribed collection of gas-filled loops in the
upper abdomen, medial and posterior to the
stomach, which may progress to a location
anterior to the hepatic flexure [1, 5, 9]. Evi-
dence of small-bowel obstruction will prob-
ably be seen [1, 5]. With barium studies, ad-
ditional mass effect will likely be shown
because the stomach and the first and second
parts of the duodenum will shift anteriorly
and laterally [1, 5, 14] (Figs. 10A and 10B).
On occasion, this type of hernia can have the
appearance of a cecal volvulus if the herni-
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Martin et al.
710 AJR:186, March 2006
A B
Fig. 623-year-old man with abdominal pain.
A, Anteroposterior projection from oral contrast small-bowel study reveals cluster of small-bowel loops (asterisk) posterior and lateral to second and third portions of
duodenum (arrow).
B, Contrast-enhanced CT scan shows abnormal loop of small bowel (arrow) in right upper quadrant and reveals right paraduodenal hernia.
Fig. 7Diagrammatic
illustration of pericecal
hernia shows loop of
ileum prolapsing (arrow)
through cecal
mesenteric defect,
behind and lateral to
cecum, into right
paracolic gutter.
ated sac contains cecum [1, 5, 14] (Fig. 11).
The zone of transition of the obstruction is
usually located near the hepatic flexure [1].
On CT, multiple gas-filled loops are located
in the lesser sac, posterior to the liver hilum,
anterior to the inferior vena cava, and be-
tween the stomach and pancreas, with taper-
ing of the herniation through the foramen of
Winslow [9] (Fig. 10C). There may be ante-
rior and lateral displacement of the stomach
and stretching of the mesenteric vessels
through the foramen of Winslow [6]. Com-
plications can arise if defects exist in the gas-
trocolic or gastrohepatic omentum, allowing
reentry of herniated loops into the greater
peritoneal cavity.
Foramen of Winslow hernias often
present a similar radiographic appearance to
that of left paraduodenal hernias. One key
feature that can be useful in distinguishing
between these entities is the presence of an
encapsulating membrane seen with left
paraduodenal hernias and not with those in-
volving the foramen of Winslow. In addi-
tion, if the entry point can be identified, it
will be slightly inferior and to the left of the
spine, delineated anteriorly by the inferior
mesenteric vein and the left colic artery with
left paraduodenal hernias, whereas with fo-
ramen of Winslow hernias, the entry point
will be relatively superior and to the right of
the spine, delineated by the liver hilum an-
teriorly. Along the same lines, mass effect
on the transverse colon more commonly in-
dicates a left paraduodenal hernia, again be-
cause of its more inferior location. Occa-
sionally, left paraduodenal hernias can be
supracolic. Finally, prominent, congested
blood vessels have more commonly been
described with paraduodenal hernias, al-
though not exclusively.
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Radiographic and Clinical Findings of Hernias
AJR:186, March 2006 711
Fig. 860-year-old man
with right lower quadrant
pain.
A, Single anteroposterior
radiograph from barium
enema study shows retro-
grade filling of herniated
distal ileum (arrows) as
loops of ileum pass poste-
rior to cecum (C) through
defect of ileocecal
mesentery to reach right
paracolic fossa.
(Reprinted with permis-
sion from [1])
B, Contrast-enhanced
axial CT scan shows loops
of small bowel (arrow)
posterior and lateral to
cecum (asterisk) in right
paracolic gutter, produc-
ing small-bowel obstruc-
tion. (Courtesy of Ghahre-
mani GG, San Diego, CA)
A B
Fig. 9Graphic
illustration of foramen of
Winslow hernia shows
bowel about to prolapse
(arrow) into lesser sac,
behind hepatoduodenal
ligament, the free edge of
the lesser omentum.
Sigmoid-Related Hernias
Two or three main types of sigmoid-related
hernias are seen, depending on the degree of
adherence to the definition of internal hernia
[5, 16]. The most common and most disput-
able, the intersigmoid type, develops when
herniated bowel, usually ileum, protrudes into
the intersigmoid fossa, formed between two
adjacent sigmoid segments and their respective
mesenteries [9]. Although this fossa is found at
65% of autopsies [1], it is debatable whether
the opening of this fossa truly is an aperture.
These hernias are often easily reducible [1]. A
second type, the transmesosigmoid hernia, oc-
curs when small bowel herniates through a
complete defect involving both layers of the
sigmoid mesocolon to lie in a position poster-
olateral to the sigmoid itself [1, 9, 16]
(Fig. 12). In this type of hernia, the orifice is
usually a long slit with its edge bounded by
branches of the inferior mesenteric artery [5].
The third and least common type, the intrame-
sosigmoid hernia, is herniation of viscera
through an incomplete defect involving only
one of the layers (usually the left leaf) of the
mesosigmoid [1, 9, 16]. The third type there-
fore consists of a hernial sac that lies within the
sigmoid mesocolon [16]. Both the second and
third types are acquired subtypes of internal
hernia, whereas the first is a normal congenital
subtype. However, these three types are radio-
graphically difficult to distinguish, and differ-
entiation is not so important because they are
treated surgically in a similar manner [9].
Clinically, these hernias present as de-
scribed, with no distinctive or characteristic
findings on history or physical examination.
If the patient has no evidence of obstruction,
these hernias can be diagnosed with postevac-
uation barium enema radiographs, which will
show sacculated ileal loops occupying the left
lower quadrant and elevation and displacement
of the sigmoid colon to the right [17]. If ob-
struction is present, however, CT findings in-
clude a cluster of Y- and X-shaped dilated
small-bowel loops entrapped behind the left
posterior and lateral aspect of the sigmoid co-
lon, with the defect most commonly located
between the sigmoid colon and the left psoas
muscle, or between sigmoid loops if it is an in-
tersigmoid type [4, 17] (Fig. 13). These bowel
loops often cause mass effect, displacing the
sigmoid colon anteromedially [17]. Additional
findings of mesenteric vessel congestion and
stranding of the fat, suggesting strangulation,
may be seen [17].
Transmesenteric Hernias
Although previously an uncommon type of
hernia, transmesenteric hernias are increasing
in incidence and surpassed the frequency of
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Martin et al.
712 AJR:186, March 2006
paraduodenal hernias in one study [4, 7, 10].
These hernias have a bimodal distribution, oc-
curring in both pediatric and adult patients. In
children, transmesenteric hernias are the most
common type of internal hernia, occurring in
35% of this patient population [1, 5, 9, 18]. In
this age group, they are thought to arise from
a congenital defect in the small-bowel mesen-
tery, near the ileocecal region or ligament of
Treitz [1, 5, 9]. One popular theory relates the
cause to prenatal intestinal ischemia and sub-
sequent thinning of the mesenteric leaves
because the prenatal intestinal ischemia is as-
sociated with bowel atresia in 5.5% of the pe-
diatric population [1, 2, 5, 18]. Other causes
postulated include intraperitoneal inflamma-
tion, trauma, partial development regression,
and fenestration of the mesentery by the colon
during the embryologic displacement into the
umbilical cord [6].
However, there is a second peak of occur-
rence in the adult population, and in this sub-
set of patients, the cause is iatrogenic, usually
related to prior abdominal surgery, especially
with Roux-en-Y anastomosis, trauma, or in-
flammation [1, 5, 6, 9, 18]. Both liver trans-
plantation and the most common type of gas-
tric bypass surgery involve the formation of a
Roux-en-Y loop at the choledochojejunos-
tomy site, and these procedures are increasing
A B
C
Fig. 1054-year-old woman with abdominal pain.
A, Anteroposterior radiograph from upper gastrointestinal series shows abnormal
cluster of small-bowel loops located in lesser sac, representing foramen of Winslow
internal hernia.
B, Oblique lateral view from same gastrointestinal series shows abnormal cluster of
small-bowel loops posterior to stomach (asterisk), indenting (arrows) and displacing
stomach anteriorly.
C, Contrast-enhanced axial CT scan shows cluster of small-bowel loops (arrow)
located in lesser sac, posterior to stomach (arrowhead).
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Radiographic and Clinical Findings of Hernias
AJR:186, March 2006 713
A B
Fig. 1170-year-old man with severe epigastric pain.
A, Anteroposterior projection of radiograph shows large collection of gas in left upper quadrant (arrows).
B, Barium enema (anteroposterior view) shows large, air-filled structure in upper abdomen (arrows), originally thought to represent a distended stomach but surgically
confirmed to be cecum involved in foramen of Winslow hernia.
Fig. 12Diagrammatic illustration of intersigmoid hernia shows bowel protruding
(arrow) through defect in sigmoid mesocolon to lie posterolateral to sigmoid
colon itself.
Fig. 1385-year-old man with abdominal pain. Axial CT scan of sigmoid-related hernia
(type 2, transmesosigmoid) reveals small-bowel loops (arrow) protruding through
defect in sigmoid mesocolon, which usually occurs between left psoas muscle
(arrowhead) and sigmoid colon (S), to lie posterior and lateral to sigmoid colon itself.
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Martin et al.
714 AJR:186, March 2006
in frequency (Fig. 14). If the Roux loop is
placed anteriorly to the transverse colon, re-
ferred to as antecolic, there will be no defect
created in the transverse mesocolon; however,
this procedure is less commonly performed
because of the required long segment of
bowel needed to travel around the transverse
colon to finally be anastomosed to the re-
maining gastric pouch. A more direct route
involves creating a defect in the transverse
mesocolon, allowing a shorter Roux limb
length. However, this second surgical proce-
dure, also known as a retrocolic type, is more
associated with the potential complication of
internal hernia (Fig. 14). Interestingly, inter-
nal hernias also appear to occur more com-
monly after laparoscopic Roux-en-Y gastric
bypass than after open Roux-en-Y gastric by-
pass, for reasons unknown [15].
Three main types of transmesenteric inter-
nal hernias are seen. The first and most com-
mon is the transmesocolic, which has been
documented to occur in 0.73.25% of patients
after laparoscopic Roux-en-Y gastric bypass
surgery [15]. The second type of transmesen-
teric internal hernia occurs when bowel pro-
lapses through a defect in the small-bowel
mesentery. Finally, the third type, known as
the Peterson type, has also been described and
involves the herniation of small bowel behind
the Roux loop before the small bowel eventu-
ally passes through the defect in the trans-
verse mesocolon [4].
Several predisposing factors have been
postulated. Although surgeons attempt to
close the defects created, they can be incom-
pletely closed or can have a breakdown or a
pulling of the suture material through the me-
socolic fat [3, 15]. Enlargement of the mesen-
teric defect can occur with repeated hernia-
tion. An additional possible predisposing
factor may be the rapid weight loss and de-
creased intraperitoneal fat that occurs in bari-
atric patients, causing enlargement of the de-
fect [4]. Transmesenteric hernias are more
likely than other subtypes to develop volvulus
and strangulation or ischemia, the incidence
of which is reported to be as high as 30% and
Fig. 14Diagrammatic
illustration shows
retrocolic Roux-en-Y
procedure, with loop of
small bowel about to
herniate through
transverse mesocolon
(arrow) at surgically
created defect, in keeping
with transmesocolic
internal hernia.
a
40%, respectively, with mortality rates of
50% for the treated groups and 100% for the
nontreated subgroups [57, 18]. Volvulus and
strangulation or ischemia may be partly
caused by the usual small aperture of the de-
fect (25 cm) in addition to the lack of encap-
sulation of the herniated loops, allowing a
large length of small bowel to herniate
through the mesenteric defect [5, 18].
Clinically, in both the pediatric and adult
populations, patients present with signs and
symptoms of small-bowel obstruction, with
periumbilical, crampy pain, nausea, and dis-
tention [1, 7, 10]. Vomiting can be a less
prominent feature than with other types of
internal hernias because of fewer gastric and
enteral secretions from the proximal gastric
pouch or Roux limb that can accumulate
above the level of obstruction [15]. Overall,
however, symptom onset is often more acute
than with other types of hernias [6]. Most
(93%) transmesenteric internal hernias in
the adult postoperative population occur
more than 1 month after surgery (mean, 235
days), and the most common cause of ob-
struction during the first postoperative
month is adhesions [4]. On physical exami-
nation, the Gordian knot of herniated intes-
tine has been described, representing a ten-
der abdominal mass [1].
Transmesenteric hernias are more difficult to
diagnose on imaging studies because their ap-
pearance and location are more variable. This is
partly because of the lack of a confining sac and
therefore their potential location anywhere in
the peritoneal cavity, although they tend to occur
more commonly in the right mid abdomen [6, 9,
10]. Most commonly, it is the Roux loop itself
that herniates with a cluster of a few loops of di-
lated small bowel in the expected location of the
Roux loop [4] (Fig. 15). On radiography, there
may be signs of small-bowel obstruction, occa-
sionally with a closed loop appearance [18].
Although the transmesenteric hernia often
causes obstruction of the limb proximal to the
enteroenterostomy site, if the hernia is distal,
an important clue may be the presence of sig-
nificant air in the gastric remnant, which is
only a normal finding in the early postopera-
tive course (Fig. 16). Otherwise, this finding
is of concern for a distal obstruction at or be-
yond the enteroenterostomy site.
Oral contrast material and cross-sectional
studies will provide a variable appearance,
depending on the type of transmesenteric her-
nia and the segment and length of herniated
bowel. If the hernia is of the first type,
through the mesocolon and consisting of only
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Radiographic and Clinical Findings of Hernias
AJR:186, March 2006 715
Fig. 1540-year-old
woman with nausea and
vomiting. Contrast-
enhanced axial CT scan
of transmesenteric
internal hernia 19 months
after Roux-en-Y
procedure shows dilated
loops of duodenum (large
black asterisk) and
jejunum (white asterisk)
in expected location of
Roux loop. Note that
Roux limb (arrowhead) is
compressed. Straight
arrows, curved arrow,
and small black asterisk
represent colon.
(Reprinted with
permission from [19])
Fig. 1636-year-old man
with sudden onset of
abdominal pain.
Radiograph
(anteroposterior
projection) shows
distended air-filled
gastric remnant, which is
normal finding in recently
postoperative patient.
However, in this patient
several months after
surgery, this finding is
most worrisome for
obstruction at distal
anastomosis of Roux-en-
Y loop.
a few loops of small bowel, oral contrast stud-
ies may show a beaked appearance of both the
afferent and efferent loops and resultant mass
effect on the stomach and transverse colon,
simulating a left paraduodenal hernia [5].
With CT as with barium studies, these hernias
can often be mistaken for or occur concomi-
tantly with a small-bowel volvulus and closed
loop obstruction, including a beaklike appear-
ance of the closely opposed afferent and effer-
ent loops [9, 18]. Again, there may be mass
effect on the stomach and transverse colon.
On the other hand, a slightly different ra-
diographic picture will emerge if the herni-
ated segment is much longer or is of the sec-
ond type, through the small-bowel mesentery.
On CT, more typical findings have been de-
scribed, in addition to the usual findings of
small-bowel obstruction with transition point
[6]. As described by Blachar and Federle [6]
and Blachar et al. [7], the presence of clus-
tered bowel loops in the periphery of the peri-
toneal cavity, lateral to the colon (a reversal of
the normal pattern), with central, inferior, and
posterior displacement of the transverse colon
is one clue (Fig. 17A). Because, as previously
mentioned, the herniated bowel is located
more commonly on the right, it is often the
hepatic flexure that is displaced inferiorly and
medially [6].
The second described finding, again by the
same authors [6, 7], involves displacement of
the overlying omental fat, with the obstructed
loops compressed and directly abutting the ab-
dominal wall (Fig. 17B). It has been suggested
that these two findings of peripherally located
small bowel and lack of omental fat between
the loops and the anterior abdominal wall
might be the most helpful CT signs, with an
overall sensitivity of 85% and 92% for each re-
spective finding [7]. The mesenteric vascula-
ture may also show an abrupt change in the
course of the superior mesenteric artery, which
is often displaced to the right, with crowding,
stretching, engorgement, and displacement of
its visceral branches [5, 6, 10, 18]. However,
further studies concluded that the only statisti-
cally significant signs were relatively nonspe-
cific findings of small-bowel dilatation with
transition point, clustering of small-bowel
loops, and mesenteric vessel abnormalities (in-
cluding displacement of the main mesenteric
trunk to the right), obtaining an overall average
sensitivity of 63%, specificity of 73%, and ac-
curacy of 77% [10]. Again, a closed loop
sign, twisting of the mesenteric vessels and the
whirl sign if volvulus is present, may also be
seen [1, 6, 9]. Occasionally, there may even be
evidence of ischemia with ascites and bowel
wall thickening present [7].
With the third type of transmesenteric
hernia associated with Roux-en-Y surgery,
known to surgeons as the Peterson type, little
has been described in the imaging literature
other than nonspecific findings of partial
small-bowel obstruction and crowding of the
mesenteric vessels.
As previously mentioned, because of their
variable imaging appearances, transmesen-
teric hernias are often confused with either
right paraduodenal or pericecal hernias. One
helpful distinguishing feature for the former
includes the presence of an encapsulating
membrane, which should be seen only with
right paraduodenal hernias. Differentiating a
pericecal hernia from a transmesenteric her-
nia can be more problematic. Location of her-
niated bowel loops (in the right upper quad-
rant for transmesenteric and right lower
quadrant for pericecal) can sometimes pro-
vide a clue, although usually a history of sur-
gery is the most helpful information.
Retroanastomotic Hernias
Retroanastomotic hernias occur when small-
bowel loops herniate posteriorly through a de-
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Martin et al.
716 AJR:186, March 2006
A B
Fig. 17CT scans in two different patients with transmesenteric internal hernias.
A, Contrast-enhanced axial CT scan of 84-year-old woman showing transmesenteric internal hernia after Roux-en-Y procedure shows dilated, fluid-filled loops of small bowel
lateral to ascending colon (arrow) and displacing omental fat because loops of bowel lie directly beneath anterior abdominal wall (arrowheads).
B, Axial contrast-enhanced CT scan at level of transverse mesocolon in a 40-year-old woman shows dilated loop of jejunum directly abutting anterior abdominal wall (white
asterisk). In addition, note compression of pancreaticobiliary limb (straight arrows), whereas Roux limb (small arrowhead) is barely visible. Large arrowhead, black asterisk,
and curved arrow indicate colon. (Reprinted with permission from [19])
Fig. 18Diagrammatic
illustration shows
retrocolic Roux-en-Y
gastric bypass
procedure. Arrow
indicates loop of small
bowel protruding
posterior to
enteroenterostomy, in
keeping with a
retroanastomotic
internal hernia.
fect related to a surgical anastomosis; they are
therefore by definition considered an acquired
type, abnormal aperture subtype of internal her-
nia. Specifically, these hernias have been most
commonly described with the Roux-en-Y for-
mation and are ever increasing in incidence as
liver transplantations and gastric bypasses for
bariatric surgeries continue to become more
frequent and widespread. If the surgery is of the
antecolic type, the borders of the aperture con-
sist of the transverse mesocolon superiorly, the
ligament of Treitz inferiorly, and the gastroje-
junostomy site and afferent limb of the jejunum
anteriorly; hence the term retroanastomotic
[5] (Fig. 18). The most common herniated loop
consists of the efferent jejunal segment, which
occurs in approximately 75% of cases [1].
However, controversy exists in the literature as
to whether this occurs more commonly with the
antecolic [5] or retrocolic [1] form of the sur-
gery. Less commonly, a very long afferent limb,
ileum, cecum, or omentum can herniate into the
retroanastomotic space. However, if antecolic
surgery is performed, the afferent loop will be
the most commonly involved segment.
As opposed to the transmesenteric type of
internal hernia related to the Roux-en-Y sur-
gery, the retroanastomotic type tends to occur
most commonly during the first postoperative
month, with half of all cases presenting during
this time [1, 5]. Of the remaining 50%, half
will occur after the first year, and the other half
(or 25% of the total) will occur between
months 2 and 12 [5]. Also in contradistinction
to the transmesocolic type, the retroanasto-
motic hernia is more common with the ante-
colic form of the surgery. Symptoms again de-
pend on whether the retrocolic or antecolic
form of the surgery was performed. If retro-
colic, symptoms may be nonspecific findings
related to a high small-bowel obstruction, such
as crampy abdominal pain and nausea [1, 5].
Typically, there is less vomiting because of the
relative lack of fluid and secretions in the gas-
tric pouch or Roux limb [19]. On physical ex-
amination, there may be a tender mass in the
left upper quadrant [1]. With the antecolic
form of the surgery, patients more commonly
present with persistent epigastric pain and ten-
derness, nonbilious vomiting, and increased
amylase [1]. Compared with other types of in-
ternal hernias, these hernias are less likely to
present with strangulation because of the large
aperture size. However, uncommonly, compli-
cations can arise when the herniated loop reen-
ters the greater peritoneal cavity through the
foramen of Winslow or a gastrohepatic or gas-
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Radiographic and Clinical Findings of Hernias
AJR:186, March 2006 717
A B
Fig. 19CT scans from two different patients showing retroanastomatic hernias.
A, Contrast-enhanced axial CT scan of retroanastomotic hernia in 35-year-old woman shows loops of dilated fluid-filled small bowel (arrow) in left upper quadrant.
B, Axial CT scan in 58-year-old woman 2 months after Roux-en-Y gastric bypass shows herniated loop posterior to jejunojejunostomy site (straight arrow) and dilated proximal
Roux limb (large arrowheads). Note decompressed distal ileal loops (small arrowheads) and colon (curved arrows). (Reprinted with permission from [19])
trocolic ligament [5]. Diagnostic consider-
ations include more common postoperative
complications such as gastric outlet obstruc-
tion, dumping syndrome, and postoperative
pancreatitis, with a delay in the diagnosis po-
tentially leading to strangulation (with mortal-
ity rates of 30% and 100% for the treated vs
nontreated groups, respectively) [1, 5].
On radiographs, because the herniated
bowel most often occurs from right to left,
there may be a collection of dilated loops in
the left upper quadrant. There also may be
significant dilation of the bypassed stomach
(Fig. 16). Upper oral contrastenhanced gas-
trointestinal studies may reveal the abnormal
loop posterior and lateral to the gastrojejunos-
tomy, often with some degree of stasis and di-
latation [1, 5]. On CT, the herniated jejunal
loops are often noted to be fixed in the left up-
per quadrant, usually associated with some
degree of dilatation (Fig. 19). However, with
the antecolic form of surgery, findings on the
oral contrastenhanced studies may be more
difficult to assess because of the difficulty in
opacifying the afferent loop. On CT, a fluid-
filled, markedly distended tubular structure is
noted. Nuclear medicine studies can often be
helpful in terms of visualizing the afferent
loop by using an agent excreted by the biliary
system into the duodenum, thereby delineat-
ing the location of the afferent loop.
Summary
Although internal hernias were previously
an uncommon cause of small-bowel obstruc-
tion, the incidence appears to be increasing as
more Roux-en-Y surgeries are performed for
various reasons, thereby creating a shift from
congenital to iatrogenic causes. It is important
for the radiologist to be aware of the imaging
findings of these hernias, particularly on CT,
because CT is rapidly becoming a mainstay in
the workup of acute abdominal pain.
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58. A.B. Rosenkrantz, M. Kurian, D. Kim. 2010. MRI appearance of internal hernia following Roux-en-Y gastric bypass surgery in
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61. Gajan Rajeswaran, Sadasivam Selvakumar, Chris King. 2010. Internal herniation of the caecum into the lesser sac: an unusual
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65. Jun-ichi Izumi, Hiroko Hirano, Takamitsu Kasuya, Masaru Odashima, Takeshi Kato, Hiroshi Yoshioka, Makoto Niwa. 2009.
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66. Ahmed R. Ahmed, Gretchen Rickards, Joseph Johnson, Thad Boss, William OMalley. 2009. Radiological Findings in
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82. P. Zonca, T. Maly, D. J. Mole, J. Stigler. 2008. Treitzs hernia. Hernia 12:5, 531-534. [CrossRef]
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89. Sheung-Fat Ko, Miao-Ming Tiao, Fu-Chen Huang, Chie-Song Hsieh, Chung-Cheng Huang, Shu-Hang Ng, Yung-Liang Wan,
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92. Shunsuke Hosono, Hiroshi Ohtani, Yuichi Arimoto, Yoshitetsu Kanamiya. 2007. Internal Hernia with Strangulation Through a
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