Internal Hernia: An Uncommon and Often-Missed Differential Diagnosis of Abdominal Pain

Abdominal pain is a common presenting symptom among patients visiting the hospital. A wide range of differential diagnoses are associated with this presentation, some of which are more uncommon than others, and require a higher degree of clinical suspicion and radiological excellence to diagnose. Although clinicians rely on physical assessment, examining a patient who is agitated and non-cooperative sometimes limits the physical exam findings, making these diagnoses even more challenging. We present a case of a middle-aged male patient who had acute abdominal pain in the setting of polysubstance abuse as confirmed by a drug screen. His initial imaging was unremarkable for a cause and the patient was intubated. After intubation and sedation, his physical examination was benign. He was extubated the next day and complained of worsening abdominal pain. His physical exam then was concerning for an acute abdomen and upon review of the initial imaging, a missed diagnosis of internal hernia was established. The patient subsequently underwent emergent exploratory laparotomy and a large section of the bowel was resected. This case highlights the importance of considering alternate diagnoses for common presentations and paying careful attention to classic radiology findings in these situations.