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Omental Infarction

Omentum Infarction

Omental infarction occurs when there is ischemia to the greater omentum. This can be idiopathic or secondary to various conditions. It is an uncommon cause of acute abdomen, with vague symptoms.


Presentation

Omental infarction (OI) is a condition where the greater omentum is subjected to ischemic damage due to interrupted blood flow. It is rare and often characterized by right lower quadrant abdominal pain [1]. One in one thousand laparotomies performed is secondary to acute abdomen arising from OI.

OI can be classified into primary and secondary [2]. In primary disease, the exact pathogenesis is unknown. There is a greater incidence of OI on the right hand side, and literature suggests that the reason lies in abnormal vasculature, stemming from embryonic factors, making it particularly vulnerable to congestion and decreased blood flow [3]. This is often referred to as primary idiopathic segmental OI [4]. In some cases the omentum first twists around itself, which then leads to OI. Conditions that predispose to omental torsion are obesity, adhesions, increased peristalsis, intra abdominal masses, and increased abdominal pressure [5]. Obesity is thought to increase the risk of torsion because of the additional fat tissue that disrupts the arterial blood supply and increases the weight of the omentum [6]. Males are more affected by idiopathic OI than females. OI has been known to occur in children as well, notably those who are obese. Secondary OI results from various medical conditions such as trauma, surgery, vascular disease and hypercoagulable states.

Because of its uncommon occurrence and non specific presentation, OI is frequently misdiagnosed, as clinicians suspect more common causes of acute abdomen, namely appendicitis, acute cholecystitis, peptic ulcer disease and so on [7]. Constitutional symptoms such as fever, as well as gastrointestinal upset (nausea, vomiting, diarrhea) are usually absent. Right sided guarding may be elicited [3].

Pseudotumor
  • Abdominal ultrasound and computerized tomography revealed pseudotumor in both cases. Symptomatic treatment and cefazolin were administered, and pain and fever subsided after 6 to 10 days.[ncbi.nlm.nih.gov]
Lower Abdominal Pain
  • The patients presented with lower abdominal pain, fever, and leukocytosis, and they exhibited a poorly defined heterogeneous low-attenuated mass containing fat in the anterior left lower abdomen.[ncbi.nlm.nih.gov]
  • Patients present with persistent severe right-sided abdominal pain, which accounts for about 3/4 of right lower abdominal pain.[healthfrom.com]
  • Case Presentation A five year old boy presented to his General Practitioner with a one day history of right lower abdominal pain after a fall at school. The boy was unable to give a history of the mechanism of the fall.[jusurgery.com]
  • Case presentation A 30-year-old man presented to the emergency department at Riyadh care hospital with lower abdominal pain of two days duration.[ispub.com]
Left Flank Pain
  • A 75-year-old woman presented with acute lower abdominal and left flank pain with rebound tenderness.[ncbi.nlm.nih.gov]
Right Upper Quadrant Pain
  • Articles will include: Evaluating the patient with right upper quadrant pain; Evaluating the patient with left upper quadrant pain; Evaluating the patient with right lower quadrant pain; Evaluating the patient with left lower quadrant pain; Acute pancreatitis[books.google.ro]
  • Cureus 9(12): e1940. doi:10.7759/cureus.1940 Abstract 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.[cureus.com]
Tenderness in the Right Upper Quadrant
  • Physical examination elicited tenderness in the right upper quadrant. The only significant laboratory value was a raised C-reactive protein of 95 mg/l.[casereports.bmj.com]
  • Her abdomen was soft, but she was tender in the right upper quadrant of the abdomen with a positive Murphy’s sign. Her full blood count, clotting, renal and bone profile serology were within normal limits with a C-reactive protein (CRP) of 23 mg/L.[cureus.com]
Peritoneal Disease
  • Surgery Volume 75, Issue 4 (April 2013) 臨床雑誌外科 75巻4号 (2013年4月) CTで術前診断し腹腔鏡下に手術しえた特発性分節性大網梗塞の1例 御井 保彦 1 , 阿部 紘一郎 , 宗實 孝 , 有川 俊治 , 高橋 洋 1 三木市立三木市民病院 外科 キーワード: 梗塞 , 術前診断 , 腹腔鏡法 , 腹膜疾患 , 網 , 腹部CT Keyword: Infarction , Omentum , Peritoneal Diseases , Laparoscopy[webview.isho.jp]
Suggestibility
  • Suggestive clinical features and diagnostic workup are addressed.[ncbi.nlm.nih.gov]
  • We report a case of 22 years male who presented with history and clinical features suggestive of acute appendicitis.[ncbi.nlm.nih.gov]
  • RESULTS: These cases revealed clinical and imaging findings on computed tomography that were suggestive and helpful in the pre-operative diagnosis of omental infarction. Findings on ultrasonography were less specific.[ncbi.nlm.nih.gov]
  • As omental infarction results in an important fat stranding that is much greater than the degree of bowel wall thickening, it suggests a narrower differential diagnosis: appendicitis, diverticulitis, epiploic appendagitis, and mesenteric panniculitis.[ncbi.nlm.nih.gov]
  • PET/CT showed an FDG-avid omental lesion that suggested peritoneal carcinomatosis. The appearance and evolution at follow-up studies confirmed the diagnosis of omental infarction, a rare complication of pancreatic surgery.[ncbi.nlm.nih.gov]

Workup

As the clinical picture is unreliable in diagnosis, more emphasis has been placed on imaging modalities. Because of their improved availability, accuracy, and thus detection rate, fewer exploratory laparotomies are being done [2] [8]. Furthermore, this may explain the apparent increased incidence of omental infarction, added to more awareness of the condition by physicians [9]. Radiology is thus paramount, as it confirms the diagnosis and influences management.

In primary omental OI, abnormalities are likely to be present in the right lower quadrant, whereas secondary OI mostly appears at the site of the causative injury. The distinction between idiopathic omental infarction, and infarction secondary to torsion can only be definitively made intra-operatively.

Imaging:

  • Abdominal ultrasound: This may show a focused hyper-echoic accumulation of fat that is not compressible.
  • Computerized tomography (CT): This may show a well demarcated lesion with fat stranding, between the anterior abdominal wall and the bowel [10]. Omental torsion may be indicated by twisted blood vessels, which is known as the swirl sign [8]. The whole lesion may have a hyperdense rim around it. Pelvic and abdominal CT scanning is the imaging modality of choice [11].

Treatment

  • Surgical intervention, however, may be necessary in order to establish definitive diagnosis and treatment. We present 2 children with SOI diagnosed as acute appendicitis preoperatively. Laparoscopy established the diagnosis and treatment.[ncbi.nlm.nih.gov]
  • One patient presented with a harmful complication that required operative treatment.[ncbi.nlm.nih.gov]
  • Conservative treatment may include antibiotics, anti-inflammatory medication, and pain medication. Greater omentum[en.wikipedia.org]
  • Treatment Omental primary segmental infarction treatment Treatment: Drug Therapy Surgical Treatment Supportive Treatment Treatment cycle: 10-30 days Cure rate: 75% Commonly Used Medicines: Ifosfamide Qian Likang Granules for Injection The affected omental[healthfrom.com]
  • Nonoperative treatment of omental infarction is safe and effective; accurate diagnosis is therefore crucial to enable a conservative approach. Suggestive clinical features and diagnostic workup are addressed.[ncbi.nlm.nih.gov]

Prognosis

  • Ultrasound focal area of increased echogenicity in the omental fat CT focal area of fat stranding swirling of omental vessels in omental torsion hyperdense peripheral halo Treatment and prognosis This condition is often self-limiting and can be managed[radiopaedia.org]
  • Prevention Omental primary segmental infarction prevention Early detection and early treatment, the prognosis of this disease is good.[healthfrom.com]
  • OI is thought to be a self-limiting, benign condition with an excellent prognosis. It may resolve spontaneously and often only requires conservative management.[prognosisapp.com]

Etiology

  • Abstract Acute abdomen is caused by a wide variety of etiologies, many of which require surgical intervention. Two boys were hospitalized for acute abdominal pain and low-grade fever.[ncbi.nlm.nih.gov]
  • Acute cholecystitis and acute appendicitis are the most likely etiologies for right upper and lower quadrant pain, respectively. However, other differential possibilities include right-sided diverticulitis and perforated colon carcinoma.[ncbi.nlm.nih.gov]
  • Although its etiology remains uncertain, predisposing factors include obesity [Surg. Today 30 (2000) 451], strenuous activity [N. Z. Med. J. 111 (1998) 211], trauma, and idiopathic omental torsion.[ncbi.nlm.nih.gov]
  • We report a case of ISIGO triggered by a unique etiology-wearing tight pants. A 75-year-old woman presented with acute lower abdominal and left flank pain with rebound tenderness.[ncbi.nlm.nih.gov]

Epidemiology

  • PubMed Google Scholar van Breda Vriesman AC, Lohle PN, Coerkamp EG, Puylaert JB: Infarction of omentum and epiploic appendage: diagnosis, epidemiology and natural history. Eur Radiol. 1999, 9: 1886-1892. 10.1007/s003300050942.[jmedicalcasereports.biomedcentral.com]
  • Radiology 226: 556–557 PubMed CrossRef Google Scholar Van Breda Vriesman AC, Lohle PNM, Coerkamp EG, Puylaert JBCM (1999) Infarction of omentum and epiploic appendage: diagnosis, epidemiology and natural history.[link.springer.com]
Sex distribution
Age distribution

Pathophysiology

  • The most common mode of presentation is pain in the abdomen, with the right lower quadrant being the commonest location.1 The pathophysiology of primary idiopathic segmental omental infarction has been postulated to be secondary to venous idiopathic and[bhj.org.in]

Prevention

  • 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[ncbi.nlm.nih.gov]
  • CONCLUSIONS: Early identification of omental infarction by abdominal US appears to prevent unjustified surgical procedures and reduce the length of hospital stay.[ncbi.nlm.nih.gov]
  • Prevention Omental primary segmental infarction prevention Early detection and early treatment, the prognosis of this disease is good.[healthfrom.com]
  • Median body mass index at presentation was 23.7 (range, 17-29), with 1 child categorized as healthy weight for age, 1 child as overweight for age, and 5 children as obese for age, based on Centers for Disease Control and Prevention criteria.[ncbi.nlm.nih.gov]
  • Candel Arenas Omental torsion: imaging techniques can prevent unnecessary surgical interventions Gastroenterol Hepatol, 25 (2002), pp. 493-496 [2] A. Abdulaziz, T. El Zalabany, A.R. Al Sayed, A.[elsevier.es]

References

Article

  1. Kamaya A, Federle MP, Desser TS. Imaging manifestations of abdominal fat necrosis and its mimics. Radiographics. 2011;31(7):2021-2034.
  2. Itenberg E, Mariadason J, Khersonsky J, Wallack M. Modern management of omental torsion and omental infarction: a surgeon's perspective. J Surg Educ. 2010;67(1):44-47.
  3. Battaglia L, Belli F, Vannelli A, et al. Simultaneous idiopathic segmental infarction of the great omentum and acute appendicitis: a rare association. World J Emerg Surg. 2008;3:30.
  4. Al-Jaberi TM, Gharaibeh KI, Yaghan RJ. Torsion of abdominal appendages presenting with acute abdominal pain. Ann Saudi Med. 2007;20(3-4):211-213.
  5. Goti F, Hollmann R, Stieger R, Lange J. Idiopathic segmental infarction of the greater omentum successfully treated by laparoscopy: report of case. Surg Today. 2000;30(5):451-453.
  6. Fragoso AC, Pereira JM, Estevão-Costa J. Nonoperative management of omental infarction: a case report in a child. J Pediatr Surg. 2006;41(10):1777–1779.
  7. Danikas D, Theodorou S, Espinel J, Schneider C. Laparoscopic treatment of two patients with omental infarction mimicking acute appendicitis. JSLS. 2001;5(1):73–75.
  8. Yoo E, Kim JH, Kim MJ, Yu JS, Chung JJ, Yoo HS, Kim KW. Greater and lesser omenta: normal anatomy and pathologic processes. Radiographics. 2007;27(3):707-720.
  9. van Breda Vriesman AC, Puylaert JB. Epiploic appendagitis and omental infarction: pitfalls and look-alikes. Abdom Imaging. 2002;27(1):20-28.
  10. Singh AK, Gervais DA, Lee P, Westra S, Hahn PF, Novelline RA, Mueller PR. Omental infarct: CT imaging features. Abdom Imaging. 2006;31(5):549-554.
  11. Naffaa LN, Shabb NS, Haddad MC. CT findings of omental torsion and infarction: case report and review of the literature. Clin Imaging. 2003;27(2):116-118.

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Last updated: 2018-06-22 06:10