Herniation of the Gallbladder Through the Epiploic Foramen into the Lesser Sac: Radiologic Diagnosis

Many abnormalities of the gallbladder both congenital (3, 4, 6, 7, 10) and acquired, have been reported. A smaller but significant number of cases of internal herniation of abdominal viscera, other than the gallbladder, through the epiploic foramen into the lesser sac, have also been published (1, 2, 5, 9, 11, 13). Only one case of herniation of the gallbladder through the epiploic foramen into the lesser sac has been reported (8), and it was discovered at surgery. So far, no radiologically diagnosed case has been reported. The purpose of this article is to report 4 such cases confirmed by surgery. In all, the author has encountered 20 cases, and his associate, George S. Rogers, has seen an additional 11, for a total of 31. It is of questionable statistical significance that only 2 of these cases have been in males, and none have been in obese patients. The pertinent anatomic features are reviewed, and the clinical implications are discussed. Case Reports Case I: N. C., a 22-year-old white female, began to experience vague postprandial upper abdominal discomfort at the age of twenty. A gallbladder examination was performed by another radiologist shortly after the onset of symptoms, and the findings were normal (Fig. 1, A). On conservative treatment, the patient was relatively asymptomatic for slightly over a year, when upper abdominal pain recurred, pre- rather than postprandial, more in the right upper quadrant, and with some poorly related bilateral infrascapular discomfort. Also, she noted a “pulling” sensation in the right upper quadrant while lying on the left side. Approximately three months after the recurrence of symptoms, gallbladder and upper gastrointestinal examinations were performed. Opacification of the gallbladder was adequate, but not quite so dense as on the earlier study, and it was slightly larger than before, apparently because of some anteroposterior flattening. More significantly, the fundus and body were displaced medially, overlying the spine (Fig. 1, B). The upper gastrointestinal examination, performed immediately after obtaining the Bucky films of the gallbladder, showed no abnormality of the upper gastrointestinal tract itself, but the gallbladder was persistently medial to the duodenal bulb, between the bulb and the lesser curvature of the stomach, even on straight frontal projections, and could not be dislodged from this position either by manual pressure or by changes in position of the patient, including upright, prone, supine, right lateral recumbent, and Trendelenburg. The adjacent margins of the bulb and gallbladder were uniformly separated and conformed closely to each other (Fig. 1, C and D). The only explanation which could be offered for these findings was that the gallbladder had herniated through the epiploic foramen into the lesser sac.