Case Report
Copyright ©The Author(s) 2022. Published by Baishideng Publishing Group Inc. All rights reserved.
World J Clin Cases. Jan 7, 2022; 10(1): 323-330
Published online Jan 7, 2022. doi: 10.12998/wjcc.v10.i1.323
Protein-losing enteropathy caused by a jejunal ulcer after an internal hernia in Petersen's space: A case report
Tomohiko Yasuda, Nobuyuki Sakurazawa, Komei Kuge, Jun Omori, Hiroki Arai, Daisuke Kakinuma, Masanori Watanabe, Hideyuki Suzuki, Katsuhiko Iwakiri, Hiroshi Yoshida
Tomohiko Yasuda, Komei Kuge, Hiroki Arai, Daisuke Kakinuma, Masanori Watanabe, Hideyuki Suzuki, Department of Gastrointestinal Surgery, Nippon Medical School Chiba Hokusoh Hospital, Chiba 270-1694, Japan
Nobuyuki Sakurazawa, Hiroshi Yoshida, Department of Gastrointestinal and Hepato-Biliary-Pancreatic Surgery, Nippon Medical School, Tokyo 113-8603, Japan
Jun Omori, Katsuhiko Iwakiri, Department of Gastroenterology, Nippon Medical School, Tokyo 113-8603, Japan
Author contributions: Yasuda T wrote the original draft; Sakurazawa N, Kuge K, Omori J, Arai H, and Kakinuma D contributed to writing, review, and editing; Watanabe M, Suzuki H, and Iwakiri K contributed to the supervision.
Informed consent statement: Informed written consent was obtained from the patient for the publication of this report and any accompanying images.
Conflict-of-interest statement: The authors declare that they have no conflict of interest.
CARE Checklist (2016) statement: The authors have read the CARE Checklist (2016), and the manuscript was prepared and revised according to the CARE Checklist (2016).
Open-Access: This article is an open-access article that was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution NonCommercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: http://creativecommons.org/Licenses/by-nc/4.0/
Corresponding author: Tomohiko Yasuda, MD, PhD, Doctor, Department of Gastrointestinal Surgery, Nippon Medical School Chiba Hokusoh Hospital, 715, Kamagari, Inzai-shi, Chiba 270-1694, Japan. t-yasuda@nms.ac.jp
Received: June 21, 2021
Peer-review started: June 21, 2021
First decision: July 14, 2021
Revised: July 29, 2021
Accepted: November 29, 2021
Article in press: November 29, 2021
Published online: January 7, 2022
Abstract
BACKGROUND

The incidence of internal hernias has recently increased in concordance with the popularization of laparoscopic surgery. Of particular concern are internal hernias occurring in Petersen's space, a space that is surgically created after treatment for gastric cancer and obesity. These hernias cause devastating sequelae, such as massive intestinal necrosis, fatal Roux limb necrosis, and superior mesenteric vein thrombus. In addition, protein-losing enteropathy (PLE) is a rare syndrome involving gastrointestinal protein loss, although its relationship with internal Petersen’s hernias remains unknown.

CASE SUMMARY

A 75-year-old man with a history of laparotomy for early gastric cancer developed Petersen's hernia 1 year and 5 mo after surgery. He was successfully treated by reducing the incarcerated small intestine and closure of Petersen’s defect without resection of the small intestine. Approximately 3 mo after his surgery for Petersen’s hernia, he developed bilateral leg edema and hypoalbuminemia. He was diagnosed with PLE with an alpha-1 antitrypsin clearance of 733 mL/24 h. Double-balloon enteroscopy revealed extensive jejunal ulceration as the etiology, and it facilitated minimum bowel resection. Pathological analysis showed extensive jejunal ulceration and collagen hyperplasia with nonspecific inflammation of all layers without lymphangiectasia, lymphoma, or vascular abnormalities. His postoperative course was unremarkable, and his bilateral leg edema and hypoalbuminemia improved after 1 mo. There was no relapse over the 5-year follow-up period.

CONCLUSION

PLE and extensive jejunal ulceration may occur after Petersen's hernia. Double-balloon enteroscopy helps identify and resect these lesions.

Keywords: Internal hernia, Ulcer, Protein-losing enteropathy, Double-balloon enteroscopy, Ischemia-reperfusion injury, Case report

Core Tip: The incidence of internal hernias has recently increased in concordance with the increasing popularity of laparoscopic surgery. Protein-losing enteropathy (PLE) is a rare syndrome involving gastrointestinal protein loss. However, its relationship with internal Petersen’s hernias remains unknown. This report presents a rare case of PLE caused by a jejunum segmental ulcer following an internal hernia in Petersen’s space. PLE and extensive jejunal ulceration may follow the reduction of Petersen's hernia. Double-balloon enteroscopy revealed the etiology of PLE and enabled minimal bowel resection in this case.