Acute Abdomen due to Primary Omental Torsion and Infarction

Omental Torsion: A Rare Mimicker of Acute Appendicitis

Omental torsion is one of the less common causes of abdominal pain, with symptoms that may be indistinguishable from more frequent pathologies, such as acute appendicitis. Computed tomography (CT) is the diagnostic modality of choice due to its characteristic findings for this condition. We report the case of a 51-year-old female with omental torsion presenting with clinical and physical examination findings indistinguishable from acute appendicitis.

Primary omental torsion with clinical masquerading as acute appendicitis and radiological key for diagnosis

Omental torsion is a medical condition characterized by the twisting of the omentum along its longitudinal axis, which leads to compromised blood flow. This condition is rarely diagnosed before surgery and can present symptoms similar to other causes of acute surgical abdomen. This report details a case of primary omental torsion initially suspected to be acute appendicitis. The patient was admitted to the hospital with symptoms of lower right quadrant abdominal pain and mild fever. Computed tomography imaging revealed a twisted mass of fatty tissue with surrounding fat stranding changes, but no signs of appendicitis were found, indicating omental torsion. The patient underwent surgery to remove the twisted and necrotic omentum, leading to an improvement in symptoms. This case highlights the challenges in diagnosis and the crucial role of computed tomography imaging in managing this rare condition.

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.

Infarcts and ischemia in the abdomen: an imaging perspective with an emphasis on cross-sectional imaging findings

Infarcts and ischemia of abdominal organs may present with acute abdominal pain, and early diagnosis is crucial to prevent morbidity and mortality. Unfortunately, some of these patients present in poor clinical conditions to the emergency department, and imaging specialists are crucial for optimal outcomes. Although the radiological diagnosis of abdominal infarcts is often straightforward, it is vital to use the appropriate imaging modalities and correct imaging techniques for their detection. Additionally, some non-infarct-related abdominal pathologies may mimic infarcts, cause diagnostic confusion, and result in delayed diagnosis or misdiagnosis. In this article, we aimed to outline the general imaging approach, present cross-sectional imaging findings of infarcts and ischemia in several abdominal organs, including but not limited to, liver, spleen, kidneys, adrenals, omentum, and intestinal segments with relevant vascular anatomy, discuss possible differential diagnoses and emphasize important clinical/radiological clues that may assist radiologists in the diagnostic process.

Laparoscopic Management of Primary Omental Torsion

Primary omental torsion is an unusual condition, known for its rarity and for the particularity of being intraoperatively diagnosed, in nearly all cases. At the clinical evaluation, this pathology commonly mimics other etiologies of acute abdomen. Hemoperitoneum and necrosis of the omentum are rarely associated with the omental torsion, but when the association is found, then it means that the vascular injuries are irreversible and the required surgical procedure may be far more complex than simple devolvulus. In search of the treatment of choice, laparoscopy proved its effectiveness as a diagnostic and therapeutic tool, while the open surgery approach can be described in many cases as being too invasive. A 37-year-old female patient presented with the generic symptoms of acute appendicitis. Surgical treatment was initiated. During laparoscopy, the abdomen was attentively explored, highlighting the presence of a twisted omentum with hemoperitoneum and necrosis. Omental excision and peritoneal drainage were performed. The evolution was favorable. Another check-up was done at 6 months postoperatively, displaying no signs or symptoms of relapse.

Omental infarction with liquefied necrosis after Roux Y gastric bypass: case report and literature review

Omental infarction is a rare phenomenon that can be idiopathic or secondary to a surgical intervention. Greater omentum division has been advocated to decrease tension at the gastro-jejunal anastomosis during laparoscopic Roux-en-Y gastric bypass (RYGB). We report a case of omental infraction complicated by liquefied infected necrosis presenting 3 weeks after antecolic antegastric RYGB. The patient underwent laparotomy and subtotal omentectomy with a protracted hospital course due to intra-abdominal abscesses, acute kidney injury and small bowel obstruction that were successfully managed non-operatively. We reviewed the available literature on omental infarction after RYGB, focusing on associated symptoms, possible etiology, timing of presentation, management and propose an alternative technique without omental division.

OMENTAL INFARCTION: SURGICAL or CONSERVATIVE TREATMENT? A CASE REPORTS and CASE SERIES SYSTEMATIC REVIEW

BACKGROUND

Omental infarction (OI) is an infrequent cause of acute abdominal pain and there is no consensus on whether conservative or surgical treatment is the best strategy when performing positive CT diagnosis.

OBJECTIVES

To assess which of the two treatments is the most commonly adopted and compare outcomes in terms of success rate in resolution of symptoms and hospital length of stay.

ELIGIBILITY CRITERIA

Case report and case series of patients with abdominal pain and positive diagnosis by CT of omental infarction.

DATA SOURCES

PubMed, Science Direct and Google Scholar in combination with cross-referencing searches and manual searches of eligible articles from January 2000 to June 2018.

PARTICIPANTS

Patients older than 18 years of age.

METHODS

Patient characteristics and results were summarized descriptively. Categorical variables were assessed by chisquare test or Fischer's exact test, and continuous variables by the Wilcoxon-Mann-Whitney or Kruskal-Wallis test. Risk factors for failure of the conservative management were identified using multivariate logistic regression.

RESULTS

90 articles were included in the final analysis (146 patients). 107 patients (73.3%) received conservative treatment with a failure rate of 15.9% (patients needing surgery) and 39 patients (26.7%) received surgery as first treatment. The mean hospital length of stay was 5.1 days for the conservative treatment group and 2.5 days for the surgery group with statistically significant differences (p = 0.00). Younger age and white blood cells count ≥12000/μl were predictive factors of conservative treatment failure.

CONCLUSIONS

Although conservative treatment is effective in most patients, surgery has advantages in terms of hospital length of stay.

"Tethered Fat Sign": The Sonographic Sign of Omental Infarction

Our purpose is to describe the ultrasound sign for a correct non-invasive diagnosis of omental infarction in children. From January 2014 to December 2018, a total of 234 children (109 boys and 125 girls, age range 3-15 y) with acute right-sided abdominal pain, admitted to our hospital with a presumptive diagnosis of acute appendicitis, were prospectively evaluated. In all patients, abdominal ultrasound was performed, and the omental fat was always evaluated. In 228 patients, the omental fat resulted to be normal or hyperechogenic, never tethered, and they results affected by other causes of abdominal pain different from omental infarction (such as appendicitis, pancreatitis, urolithiasis and others). In the remaining 6 children, we found a hyperechoic mass between the anterior abdominal wall and the ascending or transverse colon in the right abdomen quadrant, suggesting the diagnosis of omental infarction. This subhepatic mass was always tethered to the abdominal wall, motionless during respiratory excursions. We named this finding the "tethered fat sign." The diagnosis was confirmed with laparoscopy in 4 children. The other 2 children were treated with conservative therapy. In these 2 patients, a sonographic follow-up was performed, showing a progressive reduction in size of the right-sided hyperechoic mass. In conclusion, our study suggests that the presence of the "tethered fat sign" may be an accurate sonographic sign for non-invasive diagnosis of omental infarction in children.

Idiopathic omental infarction: managed conservatively

We report a case of a 49-year-old woman who presented with acutely worsening episodic abdominal pain. Workup was negative but CT of the abdomen showed right upper quadrant omental fat stranding, suggestive of fat necrosis or infarct. Treatment for the patient was largely supportive with pain management and fluid resuscitation.

Left-sided omental infarction: a rare cause of abdominal pain, discovered by CT scan

Omental infarction in adults is a rarely occurring phenomenon, with left-sided omental infarction being even more seldom. The importance of this case report lies in raising awareness of the diagnosis omental infarction as a cause of acute abdomen among doctors who work in the emergency department, in order to prevent unnecessary surgical interventions as conservative treatment generally solves the problem. Omental infarction is the result of vascular obstruction and ends in tissue ischaemia. Because of the rich vasculature of the greater omentum, anastomoses reorganise the vascularisation, which explains the mostly benign course of omental infarction. By adding omental infarction to the list of differential diagnoses in patients who present with acute abdominal pain, future management of patients with an acute abdomen can be adjusted for the optimal approach to not overlook any surgery-requiring diagnosis as well as to prevent overtreatment.

Computed tomography diagnosis of omental infarction presenting as an acute abdomen

Omental infarction is a rare cause of acute abdominal pain. Without the support of radiological evidence, diagnosis is difficult to attain owing to its infrequent incidence, low awareness among clinicians, and its nonspecific presentation that mimics other causes of acute abdomen, namely, acute appendicitis and cholecystitis. Incorrect diagnosis may lead to unnecessary invasive surgery in patients with omental infarction, a disorder that is typically managed conservatively without exposing the patient to intraoperative risks and postoperative morbidity. We report a case of a 61-year-old man who presented to the emergency department with signs of peritonitis. He was eventually diagnosed with omental infarction through computed tomography of the abdomen. He was successfully managed medically with nonsteroidal anti-inflammatory and antiemetic medications, with complete resolution of his symptoms within 2 weeks.

Omental Infarction: The Great Impersonator

A 58-year-old female presented to the emergency department with intermittent right upper quadrant pain and nausea. On examination, the patient was tender and Murphy's sign was elicited. A presumptive diagnosis of acute cholecystitis was made but an ultrasound of the abdomen revealed a thin-walled gallbladder without calculi. A computed tomography (CT) scan of the abdomen and pelvis demonstrated fat stranding involving the greater omentum and the right paracolic gutter. The patient was diagnosed with a focal omental infarction and underwent emergency laparoscopic surgery. Intraoperatively, the thickened and infarcted omental segment was dissected off the abdominal wall, liver, and mesocolon and removed through the umbilical port site using an Endo Catch™ (Covidien Ltd, Dublin, Republic of Ireland). This paper presents a rare case of omental infarction and illustrates how it can mimic the classic presentation of acute cholecystitis. The literature around the incidence, pathogenesis, and management of omental infarction is reviewed and presented to the reader.

Infarction of the greater omentum. Case report

The case of a 65 year old woman presented symptoms of acute abdomen secondary to full torsion of the greater omentum is presented, diagnosed preoperatively by CT, thus avoiding emergency surgery due to good evolution with conservative attitude. This disease is a rare cause of abdominal pain, but we include it in the differential diagnosis of acute abdomen. Currently imaging techniques allow preoperative diagnosis to avoid emergency surgery, and maintain an expectant attitude to act on patient evolution. In our case, we chose conservative attitude and the patient is asymptomatic 7 months later.

Torsion of a bifid omentum as a rare cause of acute abdomen: a case report

Background

Omental torsion is a rare and very unusual cause of acute abdominal pain. If often mimics other acute pathologies and it is very difficult to diagnose preoperatively, which can lead to deterioration of the patient. It is seldom reported in the literature.

Case presentation

We report a well-documented case of a 67-year-old white woman who complained about abdominal pain, which was slowly increasing in severity. She had no previous abdominal interventions. An abdominal ultrasound showed multiple gallstones. At laparoscopy, free hemorrhagic fluid was seen and further exploration showed torsion of the right part of her omentum. A partial omentectomy was performed. Her postoperative course was uneventful.

Conclusions

Omental torsion is a rare cause of abdominal pain. Primary omental torsion is seldom reported in the literature. Blood examinations are frequently normal. Abdominal ultrasound and computed tomography can exclude other pathologies. Exploration remains the preferred diagnostic and therapeutic modality. Surgeons should include the diagnosis of omental torsion in their differential diagnosis of acute abdominal pain.