Primary omental torsion diagnosed and treated laparoscopically: a case report

Primary segmental omental torsion, mimicking acute appendicitis

Primary segmental omental torsion (PSOT) is a very rare cause of acute abdominal pain, and it may often imitate the clinical picture of acute appendicitis. In instances of acute abdominal pain without anorexia, nausea, and vomiting, omental torsion should be included in the differential diagnosis. Any misdiagnosis may lead to major complications such as intraabdominal abscesses and adhesions. A 63-year-old overweight man with a body mass index (BMI) of 41 Kg/m2 presented to the emergency department on a remote island with acute abdominal pain. His medical history included type 2 diabetes mellitus managed with insulin, essential hypertension, osteoarthritis, and no previous abdominal operations. He reported a sharp pain originating in the epigastrium and the right hypochondrium that started five days prior. Physical examination revealed rebound tenderness and guarding across the abdomen with a positive McBurney sign. However, the patient did not report vomiting and was not nauseous. Vital signs were as follows: blood pressure 116/56 mmHg, heart rate 98 beats/min, respiratory rate 19 breaths/min, and a temperature of 38.2 0C. Laboratory results showed a white blood cell count of 10.6, neutrophils of 8.11, C-reactive protein (CRP) 74 mg/l, haemoglobin11.6 g/dl, and hematocrit 36.9%. Due to the absence of a radiographer at the hospital during that period, no imaging investigations were conducted. Diagnostic laparoscopy demonstrated diffused hemoperitoneum and necrotic mass at the site of the hepatic flexure. Initially suspected to be an advanced colon cancer, the decision was made to proceed with open surgery. The necrotic segment of the omentum was found at the right superior point of attachment of the omentum to the hepatic flexure. Consequently, the necrotic segment of the omentum was resected. A thorough investigation of the abdominal cavity did not detect any other abnormalities or pathologies. The patient recovered uneventfully and was transferred to the surgical ward. Torsion of the omentum is a very rare cause of acute abdominal pain. This case highlights the necessity of considering PSOT in the differential diagnosis of acute abdominal pain, especially in cases where symptoms are suggestive of appendicitis but diagnostic findings are negative.

Inguinal hernia leading to omental torsion: Role of CT in differentiating from other clinical mimics - a case report and literature review

Omental torsion is a very rare cause of acute abdomen. Clinically, it mimics other common pathologies such as acute appendicitis, acute diverticulitis and acute cholecystitis. It is therefore no surprise, that it was rarely diagnosed pre operatively before the advent and easy availability of modern imaging techniques. CT scan, in particular, can diagnose omental torsion with confidence pre operatively. This can make conservative treatment possible in cases of primary omental torsion and guide regarding the appropriate treatment in cases of secondary torsion. We present a case of a young male patient who presented to Emergency department with symptoms of acute abdomen. Clinical and laboratory findings were non-specific for any specific cause of acute abdomen. CT scan, however, showed omental fat stranding with whirlpool sign representing omental torsion which was seen to be secondary to left inguinal hernia. Patient was operated in emergency and necrotic omentum was resected and hernia repaired. Post-operative recovery was uneventful.

Omental torsion - A mimicker of the acute appendicitis - A case report

INTRODUCTION

Omental torsion is due to the twisting of the omentum along its axis and is observed in young male patients. The first description of omental torsion was first made by Eitel in 1899.

CASE PRESENTATION

A 35-year-old male presented with right iliac fossa pain, nausea, occasional vomiting and loss of appetite for four days. His clinical and radiological findings were suggestive of acute appendicitis. However, he was diagnosed with greater omental torsion intraoperatively and successfully managed with laparoscopic omentectomy.

DISCUSSION

Omental torsion is a rare condition with a low incidence. Preoperative diagnosis of omental torsion continues to be a challenge as the symptoms reported in the literature are usually confused with other abdominal pathologies such as appendicitis or cholecystitis etc. Preoperative US or CT scans are mandatory, and these procedures can accurately accomplish the pre-operative diagnosis. In search for the treatment of choice, laparoscopy proved its effectiveness as a diagnostic tool since it allows for confirming the diagnosis, evaluating the severity of the ischemia, and ruling out other surgical pathologies and therapeutic tools. At the same time, the open surgery approach can be described in many cases as being too invasive.

CONCLUSION

Greater omental torsion should be considered a differential diagnosis in all patients with acute abdominal emergencies.

Primary omental torsion in children: single-center experience of 17 cases

OBJECTIVE

Primary omental torsion (POT) is a rare condition in children often misdiagnosed because of a lack of clinical manifestations. Here we present insights gained from the treatment of pediatric POT cases at a single center over 8 years and summarize some influencing factors found in diagnosis and treatment, in order to reduce the misdiagnosis of POT in children in the future.

METHODS

Demographic and clinical data of 17 children with POT treated in Shanghai Children's Hospital, Shanghai Jiaotong University from June 2012 to December 2020 were reviewed.

RESULTS

The mean age of the 17 pediatric patients was 7.65 ± 2.12 years (range: 4-12 years), sixteen were male. The average time from the pain onset to operation was 73.82 ± 47.21 h (range: 21-144 h). In 5 cases, the ultrasound scan revealed a low-intensity inflammatory mass in the abdominal cavity. Only 1 of the 17 patients had normal body mass index, while others were overweight or obese. The mean computed tomography (CT) value of the mass in the lower right abdomen was - 58.74 ± 10.32 HU (range: - 70 to - 46 HU), which is close to that of its own abdominal wall fat [- 46.29 ± 9.45 HU (range: - 62 to - 32 HU)]. The location of the mass was located in front of the right colon in ten cases, except for two cases near the ligamentum teres. Five patients had whirl sign on CT images and 8 patients had pelvic fluid. Five cases were diagnosed as acute appendicitis and 12 were diagnosed as POT, the preoperative diagnosis was correct in 70.59% of cases. All 17 patients were treated with laparoscopic omentectomy. The average duration of hospitalization was 5.53 ± 1.12 days (range: 4-8 days). All cases were followed up. 1 case relapsed 8 months post operation, while the remaining cases had no complications.

CONCLUSION

POT is rare in children with acute abdominal pain, which is more common in obese boys. The fatty mass in front of colon and between rectus abdominis sheath in CT image is specific, which is helpful for diagnosis of POT. Laparoscopy is an effective method for the treatment of POT in children.