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CT signs of Internal Hernia after Roux En Y bypass
Poster Title: CT signs of Internal Hernia after Roux En Y bypass
Submitted on 02 Nov 2018
Author(s): Dr Farah Aldhaher, Dr Michael Steward, Dr Jane Young
Affiliations: Department of Radiology, The Whittington Hospital
This poster was presented at BIR annual congress 2018
Poster Views: 484
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Poster Information
Abstract: Internal hernias after Roux en Y gastric bypass

Obesity is a widely prevalent health issue casting a heavy burden on health system due to the associated morbidity. With limited effectiveness of nonsurgical approach in obtaining sustainable weight loss, The emergence of the Bariatric surgery has drastically changed the management of morbid obesity and proved successful in achieving sustained weight loss as well as decreasing the associated comorbidity.
Bariatric procedures include:

Laparoscopic Adjustable Gastric Banding:
Least invasive restrictive procedure available with less morbidity and mortality, involves inserting a band around proximal stomach laparoscopically creating small gastric pouch and adjusted via saline injection which is a disadvantage, Despite being preferred it is least effective, other complications include distal slippage, Stomal stenosis and Gastric volvulus.

Laparoscopic Sleeve Gastrectomy:
A restrictive procedure where 75% of the stomach removed laparoscopically creating small gastric pouch to achieve weight loss subsequently without the need for regular adjustment. It gained popularity for effectiveness, however several complications are encountered as: Gastric leaks and strictures.

Laparoscopic Roux-en-Y Gastric Bypass:
A malabsorptive approach where stomach is divided at fundus to create proximal pouch connected to the jejunalRoux loop creating a gastrojejunal anastomosis, While a jejunojejunal anastomosis connect the biliopancreatic limb.
It is most effective for weight loss. Complications include leak and stricture, however the most serious late complications is Internal Hernia as it is subtle presentation with non specific symptoms with a risk of Incarceration of small bowel which can lead to obstruction, infarction, and perforation of strangulated loops. As a result, internal hernias can be fatal if diagnosis and treatment delayed. which pose a diagnostic challenge for a junior registrar especially out of hours where fluoroscopic upper GI study is not available. So what signs should be looked for to predict internal hernia?
A constellation of signs to be looked for to establish the diagnosis these include:
1- swirled appearance of mesenteric fat or vessels at the root of the mesentery.
2- small-bowel obstruction.
3- migration of an anastomotic jejunojejunal suture line. This suture line is most often displaced from its typical location in the left mid-abdomen into the left upper quadrant, but it can also be displaced into the right mid abdomen. The diagnosis of an internal hernia should be suspected on CT images when a cluster of small bowel loops is seen in an atypical location, especially the left upper quadrant above the transverse mesocolon.
A study by Lockhart et al. found that 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.
Summary: Internal Hernia is a subtle presentation with non specific symptoms it carries a risk of Incarceration of small bowel which can lead to obstruction, infarction, and perforation of strangulated loops. As a result, internal hernias can be fatal if diagnosis and treatment of this complication are delayed. which pose a diagnostic challenge for a junior radiology registrar especially out of hours.References: References
1- Irene T. Ma, MD, and James A. Madura II, MD, Gastrointestinal Complications After Bariatric Surgery, Gastroenterology & Hepatology Volume 11, Issue 8 August 2015.
2- Marc S. Levine, MD, Laura R. Carucci, MD, imaging of Bariatric surgery:
Normal Anatomy and Postoperative Complications RSNA 2014.
3-Lockhart M E, Franklin N. Tessler, Cheri L. Canon, J. Kevin Smith1 Matthew C. Larrison Naomi S. Fineberg Brandon P. Roy, Ronald H. Clements3 Lockhart ME, Tessler FN, Internal Hernia After Gastric Bypass: Sensitivity and Specificity of Seven CT Signs with Surgical Correlation and Controls, American Roentgen Ray Society 2006.
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