Bandara P K B S C, Viraj Rohana A M, Pathirana Aloka
Colombo South Teaching Hospital, Kalubowila, Sri Lanka.
Faculty of Medical Sciences, University of Sri Jayawardenapura, Nugegoda, Sri Lanka.
J Med Case Rep. 2021 Jan 15;15(1):10. doi: 10.1186/s13256-020-02629-w.
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.
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.
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.
肠内疝导致的肠梗阻是一种罕见的临床病症，在无腹部手术史的腹痛患者的鉴别诊断中常被忽视。已描述了肠内疝的几个部位，其中通过温氏孔的内疝约占病例的8%。这些患者表现为与胃食管反流病症状相关的非特异性腹痛，因此诊断常被忽视。肠梗阻的常见症状可能会延迟出现，导致诊断延迟和疝入肠段坏疽。腹部X线平片和计算机断层扫描有助于诊断。开放复位是首选的治疗方法；然而，也尝试过腹腔镜复位，效果良好。
我们报告一例中年斯里兰卡男性患者，他最初表现为胃食管反流病的特征，随后出现肠梗阻特征，经检查发现有一段坏疽的小肠袢通过温氏孔疝出。在对疝出的小肠袢进行针吸减压和复位后，切除了小肠的坏疽部分并进行了回肠-回肠吻合术。用间断缝线部分闭合了较大的温氏孔。患者恢复顺利。
由于肠梗阻的延迟诊断有害，早期诊断至关重要。正如全球多例病例以及我们的患者所证明的那样，小肠通过温氏孔的内疝表现为包括胃食管反流病特征在内的非特异性症状，对于出现胃食管反流病症状且常规药物治疗无效的患者，应高度怀疑肠内疝导致肠梗阻，并应积极进行全面检查。
