Omental apoplexy: Unravelling the mystery

Idiopathic omental hemorrhage: a case report and review of the literature

BACKGROUND

A spontaneous rupture of an omental vessel can cause severe intraabdominal hemorrhage. We present a case of idiopathic omental hemorrhage caused by a vascular malformation. The literature is systematically reviewed.

CASE PRESENTATION

A 65-year-old Iranian man was admitted to the emergency department for 10 days with abdominal pain. His medical history was not significant. Fever, vomiting, nausea, or anorexia were not reported. However, he was suffering from diaphoresis and malaise at the time. He did not smoke or drink alcohol. During physical examination, blood pressure was 82/60 mmHg with a temperature of 36.6 °C; heart rate was 96 beats/minute and respiratory rate was 18 breaths per/minute. An abdominal examination revealed mild tenderness in the periumblical. The focused assessment with sonography in trauma examination yielded positive results. The complete blood count showed 14 × 103/mcL of white blood cells and 185 × 103/mcL of platelets. The hemoglobin value was 6.7 g/L at admission. To stabilize the patient's condition, a unit of packed cell was administered. A double contrast enhancement abdominal computer tomography was performed, which revealed a massive hemoperitoneum. Subsequently, an exploratory laparoscopy was performed to search for the responsible pathology. But it was not successful. The surgical plan was changed to laparotomy. The hemorrhage source was not found during laparotomy. Observation revealed a massive hemoperitoneum originating in the omental vessels. A portion of the omentum located on the greater omentum at the greater curve was removed. Based on the pathological examination of the extracted tissue, vascular malformations were identified. The patient recovered uneventfully and was discharged from the hospital 7 days after surgery. Previous reports assessing idiopathic omental bleeding were systematically reviewed. A total of 14 hits were identified in PubMed and Scopus from 2015 to November 2022 for idiopathic omental bleeding.

CONCLUSION

Presence of positive focused assessment with sonography in trauma, abdominal pain, imaging evidence of fluid accumulation, and a reduction in hemoglobin levels collectively indicate the likelihood of arteriovenous malformation occurrence. The treatment options include surgical intervention and transcatheter arterial embolization. Surgical intervention is recommended for subjects with hemodynamic instability, persistent hypotension and those whose diagnosis is unconfirmed.

Idiopathic Omental Bleeding Treated by Laparoscopic Partial Omentectomy: A Case Report and Review of the Literature

Omental bleeding is potentially life-threatening. There are many causes of omental bleeding including trauma, neoplasia, arterial aneurysm rupture, omental torsion, vasculitis, or segmental arterial mediolysis (SAM). Without remarkable pathological features, the diagnosis of idiopathic omental bleeding is made. Omental bleeding is relatively a rare disease, and there is no established treatment strategy.  A 53-year-old woman was brought to the ED for sudden onset abdominal pain. CT revealed hematoma in the omentum and was diagnosed as idiopathic omental bleeding accordingly. The patient underwent laparoscopic partial omentectomy and was discharged nine days after surgery. The pathological findings of the resected omentum were not remarkable, and the final diagnosis was made as idiopathic omental bleeding. In some case reports of omental bleeding, interventional radiology (IVR) was chosen for hemostasis, but IVR cannot resect tissue of omentum so it is difficult to make a pathological diagnosis. The surgical approach of idiopathic omental bleeding is uncommon. However, the use of the laparoscopic approach hasn't been reported in the literature. Laparoscopic partial omentectomy can provide effective hemostasis. We report laparoscopic partial omentectomy surgical procedure and review of the literature.