An otherwise healthy 48-year-old woman with no medical history presented to the emergency room with colicky abdominal pain, vomiting, and diarrhea of 2 days' duration. The results of a physical examination were unremarkable, and laboratory tests revealed a hemoglobin level of 14.9 g per deciliter and a white-cell count of 9900 per cubic millimeter. She was discharged with a diagnosis of presumed gastroenteritis. Three days later, the patient returned with persistent abdominal pain and nausea as well as newly occurring bilious vomiting. Computed tomography of her abdomen and pelvis revealed a loop of small bowel in the omental bursa (Panels A and B, arrowheads) and a widened foramen omentale (Panel B, arrow). On emergency laparotomy, a loop of jejunum was found to have herniated through the foramen omentale (Panel C, arrows). The loop of bowel was surgically reduced and enterolysis was performed. The patient had an uneventful recovery. Internal herniation through the foramen omentale should be considered when the bowel is seen within the omental bursa, which is normally vacant (Panel C, inset). Once herniation is diagnosed, surgical reduction is typically indicated to relieve the intestinal obstruction.
NEJM Volume 361:e57 December 17,2009 Number 25
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