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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]
Protein S Deficiency
  • Omental gangrene and porto-mesenteric thrombosis in a patient of protein C and protein s deficiency. Indian J Surg 2013;75 Suppl 1:409-11. 10. Park KE, Chung DJ, Kim W, Hahn ST, Lee JM.[jmgims.co.in]
Microscopic Hematuria
  • Routine investigations showed leucocytosis and microscopic hematuria in urinalysis. He was put on antibiotics and analgesics, recovered in 2 days and discharged since he was not willing for surgery.[saudisurgj.org]

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]
  • Cases recognized by imaging studies were submitted to conservative treatment that consisted of intravenous analgesics and antibiotics. Demographics, clinical presentation, laboratory findings, imaging diagnosis and outcome were analyzed.[ncbi.nlm.nih.gov]
  • Contents 1 Signs and symptoms 2 Causes 3 Diagnosis 4 Treatment 5 Prognosis 6 Epidemiology 7 See also 8 References Signs and symptoms [ edit ] Patients will present with a sudden onset of cramps/abdominal pain or a ' stitch '.[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]
  • This is the first report to describe the advantages of laparoscopy and the use of electrothermal bipolar vessel sealers, such as the LigaSure Atlas device, for the control and treatment of bleeding owing to traumatic omental infarction.[ncbi.nlm.nih.gov]

Prognosis

  • (October 2014) Prognosis [ edit ] This section is empty. You can help by adding to it . (October 2014) Epidemiology [ edit ] This section is empty. You can help by adding to it .[en.wikipedia.org]
  • 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]
  • The prognosis of this malignant tumor is extremely poor because of the lack of effective treatment, with most patients dying within 1 year of diagnosis[ 3 ].[wjgnet.com]
  • Secondary omental infarction has poor prognosis compared to primary omental infarction due to underlying disease pathology.[jmgims.co.in]

Etiology

  • 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]
  • 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]
  • 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]
  • 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]

Epidemiology

  • (October 2014) Epidemiology [ edit ] This section is empty. You can help by adding to it . (October 2014) See also [ edit ] Greater omentum References [ edit ] Barai, Kushal P.; Knight, Benjamin C. (2011-04-05).[en.wikipedia.org]
  • […] imaging techniques and increased awareness among health care providers, more children are being diagnosed with OI earlier in the disease course, preventing misdiagnosis and subsequent complications. 5 It is possible that, combined with changes in the epidemiology[acgcasereports.gi.org]
  • 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]
  • Malignant mesothelioma; epidemiologic patterns in New York State. N Y State J Med . 1981; 81 :735-738. 3. Asensio JA, Goldblatt P, Thomford NR. Primary malignant peritoneal mesothelioma. A report of seven cases and a review of the literature.[wjgnet.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]
  • To our knowledge this is the first case in which corrosive ingestion has been the pathophysiological mechanism for the etiology of late omental infarction.[tropicalgastro.com]
  • Omental infarction Omental infarction has a pathophysiology and clinical presentation similar to that of epiploic appendagitis, with the infarcted fatty tissue being a right-sided segment of the omentum.[radiologyassistant.nl]

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]
  • 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