Acute Abdomen Due to Primary Omental Torsion: Case Report

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Acute Abdomen Due to Primary Omental Torsion: Case Report Article in Journal of Emergency Medicine · November 2011 DOI: 10.1016/j.jemermed.2011.06.066 · Source: PubMed

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The Journal of Emergency Medicine, Vol. 44, No. 1, pp. e45–e48, 2013 Copyright Ó 2013 Elsevier Inc. Printed in the USA. All rights reserved 0736-4679/$ - see front matter

doi:10.1016/j.jemermed.2011.06.066

Clinical Communications: Adults ACUTE ABDOMEN DUE TO PRIMARY OMENTAL TORSION: CASE REPORT Apostolos Tsironis, MD,* Nikolaos Zikos, MD,* Christina Bali, PHD,† George Pappas-Gogos, MD,* Spiridon Koulas, MD,† and Nikolaos Katsamakis, MD* *Department of Surgery, General Hospital of Filiates, Thesprotia, Greece and †Department of Surgery, University Hospital of Ioannina, Greece Reprint Address: Apostolos Tsironis, MD, Department of Surgery, General Hospital of Filiates, Odissea 1, Ioannina 45332, Greece

, Abstract—Background: Primary torsion of the greater omentum is an uncommon cause of acute abdominal pain that mainly affects adults in their fourth or fifth decade. It was first described by Eitel in 1899. Since then, more than 300 cases have been reported in the published literature. Clinical presentation and imaging findings are often of limited value in the diagnosis of primary omental torsion (POT). The patients usually undergo laparotomy for ‘‘acute appendicitis’’ or acute abdomen of poorly defined origin. Objectives: To provide a detailed description of this rare cause of acute abdomen. Case Report: We report a case of POT in a woman of reproductive age and discuss contemporary methods in diagnosis and management of the condition. Conclusion: Nowadays, laparoscopy is a safe and effective approach for the diagnosis and management of POT, with the advantages of reduced postoperative pain and hospital stay. Conservative management has also been advocated by some authors in selected patients with a preoperative diagnosis of POT based on computed tomography findings. Ó 2013 Elsevier Inc.

(2). As stated in our previous report and in agreement with other authors, it is quite difficult to establish a preoperative diagnosis of the condition (3). Treatment consists of resection of the involved omental part. We report a case of primary omental torsion in a woman of reproductive age and discuss contemporary methods in diagnosis and management of the condition. CASE PRESENTATION A 29-year-old woman presented to our department with a 2-day history of right-sided abdominal pain that was increasing in severity, associated with nausea, vomiting, and anorexia. The patient reported transient relief of pain when bending backwards. Her past medical history was unremarkable. On physical examination, the patient had a pulse of 100 beats/min and a temperature of 36.8  C. Her blood pressure was noted to be 130/80 mm Hg. Abdominal examination revealed tenderness and guarding in the right abdomen, with diminished bowel sounds. Obturator and psoas signs were negative, and no mass was palpable. Lungs were clear to auscultation, and the cardiovascular examination was unremarkable. Laboratory tests, including a full blood count and a basic biochemical profile, were normal except for leukocytosis (13,900/mm3). An abdominal computed tomography (CT) scan was performed, which showed a large pelvic mass consistent with uterine leiomyoma but no other intra-abdominal pathology. Due to increasing

, Keywords—primary omental torsion; acute abdominal pain; greater omentum

INTRODUCTION Primary torsion of the greater omentum is a rare cause of acute abdomen that was first described by Eitel in 1899 (1). It mainly affects adults, with men involved twice as frequently as women, with the majority being overweight

RECEIVED: 26 February 2011; FINAL SUBMISSION RECEIVED: 22 May 2011; ACCEPTED: 11 June 2011 e45

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abdominal pain that was unbearable to the patient and lack of definite diagnosis, the patient underwent surgery. A midline abdominal incision was performed, which revealed a large uterine leiomyoma (12  4 cm) that was excised, and a tongue-like projection of the greater omentum (5  2.5), which was twisted around its long axis several times (Figure 1). The twisted omental part was resected. The appendix was normal and was left in place, and the exploration for Meckel diverticulum was negative. The patient’s postoperative course was normal and she was discharged 5 days later. Histological examination of the surgical specimens (Figure 2) showed uterine leiomyoma and omental segment with vascular congestion and necrosis. DISCUSSION

Figure 2. Twisted omental part and uterine leiomyoma (excised).

The greater omentum is a four-layered fatty sheet of peritoneum that suspends from the greater gastric curvature to surrounding organs, with attachments to the diaphragm (4). Responsible for the embryogenesis of the greater omentum is the dorsal mesentery (5). Primary torsion of the greater omentum (TGO) is rare, accounting for 1.1% of all cases of acute abdominal pain (6). According to previous reports, the estimated incidence of primary TGO in children undergoing laparotomy for suspected appendicitis varies between 0.024% and 0.1% (7–9). The pathophysiology of omental torsion involves rotation around its long axis, resulting in venous obstruction with subsequent edema and vascular compromise (4). Primary omental torsion (or idiopathic) refers to the rotation of a mobile omental segment around a pivotal point (usually the distal right epiploic artery), with no obvious etiology (10). Factors predisposing to primary omental torsion may include anatomic and vascular abnormalities (bifid omentum) and local variations in omental fat distri-

bution (obesity) (4,11–13). Precipitating factors include trauma and increased intra-abdominal pressure (exercise, coughing) (4,10,14,15). In the majority of cases, omental torsion is found in the right abdomen because that part of the omentum is longer and more mobile than the left side (7,16). Left-sided omental torsion is rare but has also been reported (17). The clinical picture of primary TGO is often nonspecific and largely depends on the degree and duration of torsion (18). The most important symptom is acute onset, right-sided abdominal pain, which may be associated with fever, anorexia, nausea or emesis, and leukocytosis (16,18–25). Abdominal examination reveals right-sided tenderness, guarding, and rebound tenderness. In rare cases, a mass may be palpable (16,19,23–25). In agreement with our previous report, we observed modification in pain intensity depending on the patient’s position, which may be of help in the diagnosis of omental torsion (3). In general, patients with omental torsion are less systemically unwell compared to patients with acute appendicitis, and the course of the disease extends over a longer period of time (26). Because the condition falls in the clinical context of acute abdomen, ultrasound (US) and CT scans are often performed to assist the diagnosis. US findings in omental torsion are usually consistent with a hyperechoic, noncompressible, ovoid intra-abdominal mass adherent to the abdominal wall, which is located in the umbilical region or anterolaterally to the right half of the colon. US also eliminates acute cholecystitis (4,27,28). CT scan is considered the examination of choice in cases of acute abdomen (29). If CT shows normal gallbladder and appendix with no signs suggestive of diverticulitis, the differential diagnosis is limited (29). Specific CT findings in omental torsion include diffuse streaking in a whirling pattern of fibrous and fatty folds (30). A basic advantage of CT vs. a US scan is the reliability of identifying the

Figure 1. Tongue-like projection of the greater omentum.

Primary Torsion of the Greater Omentum

mass in the characteristic location between the anterior abdominal wall and the colon (31). In our case, though, both CT and US scans failed to demonstrate the twisted omental part. Due to difficulty in the interpretation of imaging findings and the lack of specificity of clinical presentation, preoperative diagnosis is rare, involving 0.6–4.8% of cases (32). Differential diagnosis should include appendicitis, cholecystitis, cecal diverticulitis, perforated duodenal ulcer, abdominal wall hematoma, and intestinal obstruction (3,29). In women of reproductive age, salpingitis, ovarian cyst torsion, and ectopic pregnancy should also be considered (3). In children, differential diagnosis should also include Meckel diverticulum and mesenteric adenitis (3). Finally, torsion of accessory spleen is another diagnostic possibility, due to the fact that accessory spleen, when it exists, usually resides inside the omentum (33). Surgery remains the gold standard for diagnosis and management of primary TGO (25). Intra-operative findings suggestive of the condition include the presence of variable amounts of intraperitoneal serosanguinous fluid along with the absence of any intra-abdominal pathology (3,18). Treatment of choice is resection of the affected omental part with or without appendectomy (12,34–36). The mode of resection regarding open or laparoscopic approach depends on the available equipment and the surgeon’s experience. We agree with other authors that laparoscopic approach is a safe and effective alternative for the management of primary TGO (3,6,32,34,37–40). Conservative management has also been reported when diagnosis was confirmed preoperatively by CT (41,42). We strongly recommend surgical management of primary omental torsion because delayed or conservative treatment may lead to several complications such as intra-abdominal abscess, sepsis, and adhesion formation (43). CONCLUSION Primary torsion of the greater omentum should be considered in any case of acute abdominal pain in both children and adults. In the majority of cases, clinical and imaging findings are of limited value in the establishment of a preoperative diagnosis. Surgery is the mainstay in the diagnosis and management of primary omental torsion for immediate relief of symptoms and avoidance of potential complications related to conservative management. REFERENCES 1. Eitel GG. Rare omental torsion. NY Med Rec 1899;55:715–6. 2. Mavridis G, Livaditi E, Baltogiannis N, Vasiliadou E, Christopoulos-Geroulanos G. Primary omental torsion in children: ten-year experience. Pediatr Surg Int 2007;23:879–82.

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