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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].

Inguinal Mass
  • Physical examination revealed marked tenderness over the right lower quadrant and a right inguinal mass. Clinical laboratory studies indicated leukocytosis (white blood cell count, 10270/mm 3 ).[synapse.koreamed.org]
Overeating
  • MATERIALS AND METHODS: Over a 3 year period, 15 patients with a history of colonic resection were identified as having a CT diagnosis of postoperative omental infarction.[ncbi.nlm.nih.gov]
  • The greater omentum, which is composed of a double layer of peritoneum, originates from the greater curvature of the stomach and extends anteroinferiorly to drape over the transverse colon. It has a variable length of 15 to 36 cm.[radiologykey.com]
  • The CT findings may persist for years, but the lesion will usually shrink over time. Primary omental infarctions tend to remain ill-defined, while the secondary tend to develop a well-defined hyperdense rim [1, 4].[eurorad.org]
Left Flank Pain
  • A 75-year-old woman presented with acute lower abdominal and left flank pain with rebound tenderness.[ncbi.nlm.nih.gov]
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 pp.404[webview.isho.jp]
Abdominal Fullness
  • Physical examination revealed epigastric and right upper abdominal fullness, and laboratory studies showed elevated erythrocyte sedimentation rates, with normal leukocyte counts and coagulation profiles.[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]
Dysuria
  • The patient denied any associated symptoms such as nausea, vomiting, fevers, chills, dysuria or change in urine or bowel habits. Per patient report, she had 1-2 soft, brown bowel movements per day.[jdeonline.in]
  • Clinically, omental infarction often mimics acute appendicitis because patients usually present with acute onset of right lower quadrant pain, and approximately 50% report nausea, vomiting, bowel disorders, dysuria, and fever [ 7 ].[ajronline.org]
  • In 50% of the cases, the infarction is associated with fever, anorexia, nausea, vomiting and dysuria. Occasionally, as with our patient, the pain may change with movements, which is a suggestive factor for the diagnosis [ 1, 2, 14 ].[em-consulte.com]
Cesarean Section
  • The majority of the secondary cases followed cesarean section in our series.[saudisurgj.org]
  • Phillips RW, Peterson CM: Infarction of the omentum after cesarean section. A case report. J Reprod Med. 1988, 33: 382-384. 6. Maternini M, Pezzetta E, Martinet O: Laparoscopic approach for idiopathic segmental infarction of the greater omentum.[jmedicalcasereports.biomedcentral.com]
Scrotal Pain
  • In cases of omental infarction caused by inguinal herniation, the patient can present with acute scrotal pain instead of the previously discussed acute abdomen.[cureus.com]
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].
Bloody Ascites
  • Bloody ascites was also observed in the abdominal cavity. We resected the nonviable segmental omentum, and the ovarian cyst was removed by the gynecologist using laparoscopic procedures. Final pathological findings confirmed POI.[ingentaconnect.com]
  • (b) A dark purple mass on the left side in the lower part of the omentum and bloody ascites in the left abdomen.[onlinejets.org]
Fibrinoid Necrosis
  • Final pathological examination revealed hemorrhagic infiltrations, thrombosis of the tissue, acute inflammatory cellular infiltrate, and fibrinoid necrosis, and POI was diagnosed [Figure 3].[onlinejets.org]

Treatment

  • You can help by adding to it. ( October 2014 ) Treatment [ edit ] Conservative treatment may include antibiotics, anti-inflammatory medication, and pain medication.[en.wikipedia.org]
  • 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]
  • All patients received analgesic, anti-inflammatory and antibiotic treatment, which has also been proposed by other authors, 1,2 although antibiotic treatment has been disputed in other cases. 3,4 After clinical improvement, patients were discharged from[elsevier.es]

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]
  • Peritoneal Mesothelioma Prognosis Mesothelioma in all its forms typically has a rather poor prognosis, which can vary based on a variety of factors including the location and stage.[mesotheliomadiagnosis.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]
  • 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

  • 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]
  • Since the omental infarct as etiology of acute abdominal pain is uncommon, we highlight some of the possible etiologies and emphasize the importance of accurate diagnosis and appropriate treatment of omental infarction.[pagepress.org]

Epidemiology

  • […] 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]
  • JBR-BTR. 2002, 85: 193-199. 14. 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. 15.[jmedicalcasereports.biomedcentral.com]
  • Cardiology, Angiology (178) Pharmacology (171) Genetics (146) Oncology, Radiation Therapy (143) Gastroenterology and Hepatology (137) Obstetrics, Gynaecology (114) Endocrinology, Metabolism (113) Dermatology (110) Psychiatry, Psychology, Sexology (104) Epidemiology[portal.mefanet.cz]
  • Infarction of omentum and epiploic appendage: diagnosis, epidemiology and natural history. European Radiology. 1999; 9 (9):1886–1892. [ PubMed ] [ Google Scholar ] 32. Karak PK, Millmond SH, Neumann D, Yamase HT, Ramsby G.[ncbi.nlm.nih.gov]
  • Puylaert, "Infarction of omentum and epiploic appendage: diagnosis, epidemiology and natural history," European Radiology, vol. 9, no. 9, pp. 1886-1892, 1999. [32] P. K. Karak, S. H. Millmond, D. Neumann, H. T. Yamase, and G.[cyberleninka.org]
Sex distribution
Age distribution

Pathophysiology

  • Its basic histological findings allow us to understand its pathophysiology.[em-consulte.com]
  • 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]
  • Internal Medicine (534) Paediatrics, Neonatology (442) Pathology and Forensic Medicine (400) Surgery, Traumatology and Orthopaedics (323) Infectology (268) Physiology and Pathophysiology (256) Medical Chemistry and Biochemistry (223) Microbiology (213[portal.mefanet.cz]
  • 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]
  • SOI produces characteristic radiological appearances on CT scan; hence, correct diagnosis using this form of imaging may prevent unnecessary surgery. We present the case of a young woman who was treated… CONTINUE READING[semanticscholar.org]

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: 2019-07-11 21:28