A Case of Gangrenous Cholecystitis due to Herniation of the Gallbladder through the Foramen of Winslow with Severe Torsion

Abstract Background Intestinal obstruction due to internal herniation of the bowel is a rare clinical entity which is often overlooked in the differential diagnosis of patients with abdominal pain who have no previous history of abdominal surgery. Several sites of bowel internal herniation have been described, amongst which internal herniation through the foramen of Winslow accounts for about 8% of cases. These patients present with nonspecific abdominal pain associated with symptoms of gastroesophageal reflux disease, and hence the diagnosis is often overlooked. The usual symptoms of intestinal obstruction can be delayed, which results in a delay in diagnosis and gangrene of the herniated bowel segment. Abdominal radiographs and computed tomography are helpful in the diagnosis. Open reduction is the management of choice; however, laparoscopic reduction has also been attempted, with good results. Case presentation We report a case of a middle-aged Sri Lankan man who presented with features of gastroesophageal reflux disease, developed features of intestinal obstruction and was found to have a gangrenous small bowel loop which had herniated through the foramen of Winslow. Following needle aspiration and reduction of the herniated small bowel loop, the gangrenous part of the small bowel was resected and an ileoileal anastomosis performed. The large foramen of Winslow was partially closed with interrupted stitches. The patient made an uneventful recovery. Conclusion Since delayed diagnosis of bowel obstruction is detrimental, it is of utmost importance to diagnose it early. Because internal herniation of the small bowel through the foramen of Winslow presents with nonspecific symptoms including features of gastroesophageal reflux disease, as documented in several cases worldwide and also presented by our patient, there should be a high degree of suspicion of internal herniation of the bowel causing bowel obstruction and low threshold for extensive investigation of patients presenting with symptoms of gastroesophageal reflux disease which does not resolve with usual medication.

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Hepatobiliary and Pancreatic: Plate-like atelectasis mimics pneumoperitoneum in patient with acute gangrenous cholecystitis

Journal of Gastroenterology and Hepatology ◽

10.1111/jgh.13274 ◽

2016 ◽

Vol 31 (5) ◽

pp. 911-911

Author(s):

N Lakananurak

Keyword(s):

Gangrenous Cholecystitis

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Foramen of Winslow hernia

Surgical Practice ◽

10.1111/j.1744-1633.2007.00352.x ◽

2007 ◽

Vol 11 (2) ◽

pp. 81-83 ◽

Cited By ~ 2

Author(s):

Cherry E. Koh ◽

Simon D.S. Woods ◽

Val Usatoff

Keyword(s):

Foramen Of Winslow

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Use of a predictive equation for diagnosis of acute gangrenous cholecystitis

The American Journal of Surgery ◽

10.1016/j.amjsurg.2004.07.013 ◽

2004 ◽

Vol 188 (5) ◽

pp. 463-466 ◽

Cited By ~ 23

Author(s):

Liz Nguyen ◽

Shawn P. Fagan ◽

Timothy C. Lee ◽

Nori Aoki ◽

Kamal M.F. Itani ◽

...

Keyword(s):

Predictive Equation ◽

Gangrenous Cholecystitis

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Prediction of Patients with Acute Cholecystitis Requiring Emergent Cholecystectomy: A Simple Score

Gastroenterology Research and Practice ◽

10.1155/2010/901739 ◽

2010 ◽

Vol 2010 ◽

pp. 1-5 ◽

Cited By ~ 33

Author(s):

Wael N. Yacoub ◽

Mikael Petrosyan ◽

Indu Sehgal ◽

Yanling Ma ◽

Parakrama Chandrasoma ◽

...

Keyword(s):

Heart Rate ◽

Logistic Regression ◽

Acute Cholecystitis ◽

High Probability ◽

Acute Inflammation ◽

Gallbladder Wall ◽

Cutoff Score ◽

Gangrenous Cholecystitis ◽

Pathological Review ◽

Low Probability

The objective was to develop a score, to stratify patients with acute cholecystitis into high, intermediate, or low probability of gangrenous cholecystitis. The probability of gangrenous cholecystitis (score) was derived from a logistic regression of a clinical and pathological review of 245 patients undergoing urgent cholecystectomy. Sixty-eight patients had gangrenous inflammation, 132 acute, and 45 no inflammation. The score comprised of: age > 45 years (1 point), heart rate > 90 beats/min (1 point), male (2 points), Leucocytosis > 13,000/mm3(1.5 points), and ultrasound gallbladder wall thickness>4.5 mm (1 point). The prevalence of gangrenous cholecystitis was 13% in the low-probability (0–2 points), 33% in the intermediate-probability (2–4.5 points), and 87% in the high probability category (>4.5 points). A cutoff score of 2 identified 31 (69%) patients with no acute inflammation (PPV 90%). This scoring system can prioritize patients for emergent cholecystectomy based on their expected pathology.

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