Internal herniation is a well-described complication after a
gastric bypass, particularly when performed laparoscopically, although it is rarely described following a total
gastrectomy. A 55-year-old lady presented with a 24-hour history of
vomiting and rigors 10 months after a radical total
gastrectomy with Roux-en-Y reconstruction for a gastric
adenocarcinoma. Computed tomography (CT) showed a complete small bowel obstruction and a mesenteric swirl sign, indicating a possible
internal hernia. The entire small bowel was found at
laparotomy to have migrated through the mesenteric defect adjacent to the site of the previous jejunojejunostomy and was dark purple and aperistaltic. The small bowel was reduced through the defect. At a second
laparotomy, the small bowel looked healthy and the defect was repaired. Postoperative recovery was unremarkable. Of numerous signs described, the mesenteric swirl sign is considered the best
indicator on CT of an
internal hernia following Roux-en-Y reconstruction in
gastric bypass surgery. A swirl sign on CT in a patient with
abdominal pain should always raise the suspicion of an
internal hernia.