Introduction A rare cause of small bowel obstruction (SBO), an internal hernia via the foramen of Winslow offers a high risk of strangulation because of its delayed identification.We present a 33-year-old male patient who developed gangrenous SBO as a result of incarceration in the lesser sac through the Winslow foramen.Case presentation A 33-year-old male presented with acute abdominal pain, vomiting, and obstipation.Imaging revealed dilated small bowel loops and a transition point near the foramen of Winslow.Emergency laparotomy confirmed a hernia with ischemic bowel, necessitating resection and anastomosis.The patient recovered well postoperatively.Discussion Foramen of Winslow hernias (FWH) are exceedingly rare (<0.1% of hernias) and often present with nonspecific symptoms, leading to diagnostic delays.This case underscores the critical role of early imaging, particularly computed tomography (CT), in identifying FWH and preventing catastrophic outcomes like bowel ischemia.Timely surgical intervention is paramount, as delayed treatment can result in significant morbidity or mortality.Clinicians should maintain a high index of suspicion for internal hernias in cases of atypical SBO, even in patients without prior surgical history.Conclusion A foramen of Winslow hernia is a surgical emergency that needs to be identified quickly in order to avoid serious consequences.Early imaging and a high level of clinical suspicion are essential.
Alex: Welcome to another episode of ResearchPod. Sam, I came across this case report about a man with severe stomach pain that turned out to be something quite unusual—what caught your eye about it?
Sam: This is a case report from researchers at Lancet General Hospital in Ethiopia. It details a 33-year-old man who arrived at the emergency room with sudden abdominal pain, repeated vomiting, and no bowel movements or gas for three days. The central puzzle was a small bowel obstruction with no obvious cause like prior surgery. A CT scan spotted a rare internal hernia through the foramen of Winslow—a natural opening—before surgery. That allowed early repair and removal of dead bowel.
Alex: So the blockage hid inside, with no external clues? What made the bowels get trapped there?
Sam: Yes. A small bowel obstruction blocks the tube-like small intestine, where most digestion happens. Here, loops of small intestine slipped through a tiny natural hole in the abdominal wall into a pocket behind the stomach. Think of it like a garden hose snagging through a gap in a fence—you can't see it from outside, but it kinks and stops the flow.
Alex: That makes sense for why it's hard to spot. Walk me through this foramen of Winslow—why does it trap bowel like that?
Sam: The foramen of Winslow is a small natural doorway, about the size of a finger. It connects the main abdominal space to the lesser sac, a pocket behind the stomach. Normally, belly pressure keeps intestines out. But here, a section called the jejunum slipped in, twisted, and cut off its blood supply—like a rope getting jammed in a pulley, swelling upstream and starving downstream.
Alex: So the CT showed exactly where it was pinched, before the tissue died?
Sam: Right. The patient had a tender belly with no gut sounds and high white blood cells, hinting at inflammation. The urgent CT—with dye for clear views—revealed swollen bowel loops clustered in the lesser sac. Vessels stretched toward the foramen like a bird's beak, with early signs of poor blood flow such as wall thickening.
Alex: That bird's beak sign pointed to the exact spot. What did surgery reveal?
Sam: Surgeons opened the abdomen down the middle. They found about 40 centimeters of mid-jejunum fully dead from lack of blood. They drained bloody fluid, freed the bowel, cut out the dead section, joined the healthy ends, and stitched the foramen shut. The patient ate by day three and went home by day six.
Alex: Even in a resource-limited hospital, CT turned a potential surprise into a targeted fix. Why is this spot so risky?
Sam: It's near major vessels to the liver and the big vein returning blood to the heart. Bowel slipping in can squeeze those or itself, cutting blood flow faster than in other spots. This case had no prior surgery—just likely loose bowel attachments or pressure shifts, common in adults 20 to 60.
Alex: That explains the quick escalation. Symptoms started vague—pain around the belly button, vomiting food bits, no stool or gas?
Sam: Correct, classic for a blockage near the intestine's start but easy to mistake for common issues. The CT ruled out tumors, showed the swollen transition point, hemorrhagic fluid, and trapped loops—letting surgeons prepare precisely.
Alex: Even though rare, this stresses CT for unusual blockages. Does the paper note why these get missed?
Sam: Yes—symptoms mimic everyday belly pain. Without CT details like crowded loops or converging vessels, it looks generic. Plain X-rays just hint at blockage. Here, CT caught mild fluid irritation before full infection, buying time.
Alex: This case shows how CT bridges the gap in spotting internal traps early. Thanks for joining me, Sam—thanks for listening to ResearchPod.