Closed loop small bowel occlusion through a congenital defect of the greater omentum.

An 80-year-old male was admitted with a 15-h history of persistent epigastric and peri umbilical pain. Pain had spontaneously appeared during night and awakened the patient. There was neither nausea nor vomiting. Physical examination revealed moderate epigastric and supraumbilical abdominal tenderness. The patient was without surgical antecedent. Laboratory tests were normal. Abdominal ultrasound suspected small bowel subocclusion. Contrast enhanced abdominal MDCT confirmed small bowel sub-occlusion with distension of small bowel loops in the epigastric area, left upper quadrant and left flank. A transitional zone between dilated and collapsed loops was individualised in the infra-umbilical area. During dynamic multiaxial MPR analysis around the point of constriction a typical close loop configuration (Fig. A) was recognised and the diagnosis of internal hernia was proposed. The patient underwent laparatomy and the diagnosis of internal hernia was confirmed. The orifice consisted of a 2 cm congenital defect through the free edge of the greater omentum (Fig. B, white arrowhead). The exact nature of the hernial orifice was retrospectively identified on abdominal MDCT through scrupulous analysis of the surrounding vessels which were recognised as little omental veins (Fig. C) (white arrows on A & C).