Case Report: A rare case of acute small bowel obstruction from a paraduodenal Treitz hernia: navigating diagnostic and surgical challenges

Background: Internal hernias are a rare but critical cause of small bowel obstruction, with paraduodenal hernias being the most common subtype. They pose a significant diagnostic challenge due to non-specific symptoms and can lead to catastrophic outcomes like bowel strangulation. Objectives: This report details a case of acute small bowel obstruction secondary to a paraduodenal Treitz hernia to highlight the diagnostic and therapeutic challenges and discuss key management decisions. Case presentation: A 53-year-old male, smoker, with no surgical history, presented with severe progressive abdominal pain, vomiting, and constipation. Examination revealed abdominal tenderness and rigidity. Laboratory findings showed leukocytosis with neutrophilia, a markedly elevated creatine kinase and C-reactive protein. CT scan confirmed a small bowel obstruction with a tight transition point. An initial laparoscopic exploration was converted to open laparotomy due to poor visualization, revealing a non-strangulated paraduodenal Treitz hernia, which was successfully reduced. The patient's postoperative course was uncomplicated, with a rapid return to a liquid diet by postoperative day one. Conclusion: This case underscores that internal hernias must be considered in patients with small bowel obstruction and no prior abdominal surgery. Timely CT imaging is crucial for diagnosis, and surgical flexibility, with a readiness to convert to open laparotomy, is essential for safe management and optimal outcomes.