Table of Contents  
CASE REPORT
Year : 2015  |  Volume : 8  |  Issue : 4  |  Page : 534-536  

Case report of primary omental torsion


1 Department of General, Laporoscopic and Endoscopic Surgery, Surya Hospital Pvt. Ltd., Sahyadri Speciality Hospital, Pune, Maharashtra, India
2 Department of Radiology, Surya Hospital Pvt. Ltd., Sahyadri Speciality Hospital, Pune, Maharashtra, India

Date of Web Publication14-Jul-2015

Correspondence Address:
Jaisingh Shinde
Surya Hospital Pvt. Ltd., 1317, Kasba Peth, Pune - 411 011, Maharashtra
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0975-2870.160830

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  Abstract 

Omental torsion is an uncommon diagnosis for an acute abdomen. We present a case of a 45-year-old obese male who presented with acute pain on the right side of the abdomen for 2 days. Ultrasonography and computed tomography abdomen suggested an omental torsion, which was confirmed on laparoscopy. The omental infarct was resected, and the patient is asymptomatic for the past 15 months.

Keywords: Omentum, primary, torsion


How to cite this article:
Shinde J, Pandit S, Fernandes A, Joshi V, Naik R. Case report of primary omental torsion. Med J DY Patil Univ 2015;8:534-6

How to cite this URL:
Shinde J, Pandit S, Fernandes A, Joshi V, Naik R. Case report of primary omental torsion. Med J DY Patil Univ [serial online] 2015 [cited 2022 Oct 7];8:534-6. Available from: https://www.mjdrdypu.org/text.asp?2015/8/4/534/160830


  Introduction Top


Omental torsion is an uncommon diagnosis for acute abdominal pain and is not considered in the primary diagnosis. Primary torsion of the omentum occurs when it twists around its long axis, impeding its vascularity. Ultrasonography (USG) and computed tomography (CT) scan being done routinely for evaluation of acute abdomen one is able to diagnose this condition. Laparoscopy is now an extended tool for diagnosis and along with its therapeutic application forms the first line of treatment.


  Clinical Presentation Top


A 45-year-old obese male, weighing 120 kg, presented with acute pain on the right side of the abdomen since 2 days. The pain followed lifting of a heavy weight. This was the 1 st episode of pain and was accompanied with vomiting and low-grade fever (99.6°F). There were no accompanying urinary disturbances or constipation.

On examination, there was guarding on the right side of the abdomen. Due to obesity not much could be appreciated clinically. The clinical differential diagnosis of acute appendicitis, acute cholecystitis, acute pancreatitis was made, and patient was investigated accordingly Patient was simultaneously started on symptomatic treatment. Investigation showed a total leukocyte count as 10,600. His liver function test's, urine analysis and serum amylase were normal.

Patient was subjected to USG abdomen and pelvis, which showed echogenic, well-defined lesion in the right hypochondrium beneath the anterior abdominal wall, below the level of the inferior margin of the liver and the gall bladder. There was a central hypo echoic area. No calcifications were seen. There was no vascularity on color Doppler. The gallbladder (GB) appeared normal. All the solid organs appeared normal. The bowel loops were unremarkable. There was no free fluid in the paracolic gutters or the pelvis. Appendix could not be imaged due to bowel gas and food residue within colon causing artifacts.

A CT scan was advised to rule out appendicitis, cholecystitis and secondary omental inflammation. CT scan showed soft tissue stranding of fat in the infrahepatic region, beneath the anterior abdominal wall. It had well-defined margins. It was anterior to the ascending colon and hepatic flexure, in the expected location of the omentum. Appendix was retrocecal and normal. Solid organs appeared normal. There was no free fluid in the paracolic gutters or pelvis. The features favored possibility of omental infarction or panniculitis [Figure 1].{Figure 1}

A diagnosis of primary omental infarct was made based on the imaging finding. Since patient did not improve appreciably, and the fever persisted, patient was subjected to diagnostic laparoscopy [Figure 2] and [Figure 3].{Figure 2}{Figure 3}

Laparoscopy showed that the right side of the greater omentum was adherent to the anterior abdominal wall, in the region below the liver, over an area of about 2-3 inch 2 . There was a well-demarcated segment of omental infarct extending 6″ proximally from the abdominal wall attachment. The rest of the abdomen viz. appendix, GB colon was normal. The segment of omentum showing infarct was resected using the harmonic scalpel. The specimen was placed in a retrieval bag. However, it could not be extracted because of its big size and had to be broken into pieces by finger fracture method. Keeping the specimen bag intact, piecemeal retrieval was done. The specimen weighed 250-g. No drainage tube was placed.

  • Patient had an uneventful recovery and discharged after 48 hours.
  • Histopathology report showed omentum having fat necrosis with inflammation.
  • 15 months postoperatively patient is asymptomatic.

  Discussion Top


Omental torsion is a rare entity occurring in 4 cases/1000 [1] of all cases of acute abdominal pain abdomen. It was first documented by Eitel in 1899 [2] as an independent entity, hence called primary omental torsion.

The omentum is a double fold of peritoneum joining the stomach to the posterior abdominal wall, anterior to the transverse colon. It is derived from the dorsal mesogastrium in the embryo and is composed of fat, blood vessels, lymphatics and cellular tissues. Being an integral part of the immune system, its dynamism is reflected when in 1906 Rutherford Morrison coined the term, "the abdominal policeman" [3] for the omentum. He linked this structure "to a jellyfish that coursed about the peritoneal cavity taking care of whatever mischief is brewing." Its phagocytic activity helps localize any inflammatory pathology, hence is not considered in the primary diagnosis of acute abdominal pain. The common causes like appendicitis, cholecystitis, diverticulitis, etc. are considered first.

Omentum has no fixed position, and profound changes are known to occur by mechanical factors, wherein the mobile segment rotates around a proximal fixed point. Donhauser and Lauser [4] suggested the terminology "primary" and "secondary" for omental torsion depending upon any definitive known cause such as hernia, adhesions tumor, and cyst. Once rotation occurs around a pivotal point on its long axis [5] there is venous occlusion of the affected omentum, which becomes subsequently congested, edematous, and hemorrhagic and finally evolves into an infarct. The clinical signs and symptoms would depend upon the stage when the patient is seen. The late sequelae of this pathology could be localized peritonitis or adhesions. Adams [6] proposed "predisposing" and "precipitating factors." Predisposing factors are obesity, (found in 70% of cases), [7] aberrant arrangement of blood vessels, especially on the right side where the omentum is large and long, torsion is more common. Precipitating factors include violent exercise, hyper-peristalsis or trauma.

Ultrasonography shows a complex mass of solid material with hyper and hypo echoic shadows. It also rules out other abdominal causes of pain. A CT scan is warranted as it is more sensitive because of fat content of omentum. In the torsion there is a concentric distribution of fibrous and fatty folds, which converge radially toward the torsion - the "whirl sign." [8] With these investigations, the diagnosis of primary omental torsion is now being made more often. The incidence of a correct preoperative diagnosis is now 0.6-4.8%, [9] but the frequency of an accurate diagnosis is increasing.

With an early diagnosis, conservative treatment has been known to relieve the symptoms and is considered as an initial treatment. Itenberg et al. advocates close monitoring for 48 hours. To what extent surgery should be postponed is an arbitrary judgment. [1] In the case of nonresponders, with bowel obstruction or signs of peritonitis, laparoscopic surgery is advised. It serves both as a diagnostic and therapeutic tool, as it can inspect the complete abdomen. The segment showing infarct can be excised at the same sitting. [10]


  Conclusion Top


Omental torsion should be considered in the differential diagnosis of acute abdomen, especially in obese individual with a history of violent trauma, exercise and no previous abdominal surgery. USG and CT scan helps in the diagnosis. Laparoscopy should be considered early, especially in obese individuals in whom the diagnosis can be delayed increasing morbidity. Appropriateness of conservative management is still under review, and this rare diagnosis of primary omental torsion should be considered.

 
  References Top

1.
Itenberg E, Mariadason J, Khersonsky J, Wallack M. Modern management of omental torsion and omental infarction: A surgeon's perspective. J Surg Educ 2010;67:44-7.  Back to cited text no. 1
    
2.
Eitel GG. Rare Omental torsion. N Y Med Rec 1899;55:715.  Back to cited text no. 2
    
3.
Morrison R. On functional aspects of the greater omentum. Br Med J 1906;1:76.  Back to cited text no. 3
    
4.
Andreuccetti J, Ceribelli C, Manto O, Chiaretti M, Negro P, Tuscano D. Primary Omental Torsion (POT): A review of literature and case report. World J Emerg Surg 2011;6:6. Published online 2011 Jan 26. doi: 10.1186/1749-7922-6-6.  Back to cited text no. 4
    
5.
Steyaert H, Calla JS. Laparoscopic approach to primary infarction of the greater omentum. Surg Laparosc Endosc Percutan Tech 1997;7:97-8.  Back to cited text no. 5
    
6.
Adams JT. Primary omental torsion of omentum report of 6 cases. Arch Surg 1954;69:657-62.  Back to cited text no. 6
    
7.
Atar E, Herskovitz P, Powsner E, Katz M. Primary greater omental torsion: CT diagnosis in an elderly woman. Isr Med Assoc J 2004;6:57-8.  Back to cited text no. 7
    
8.
Yoo E, Kim JH, Kim MJ, Yu JS, Chung JJ, Yoo HS, et al. Greater and lesser omenta: Normal anatomy and pathologic processes. Radiographics 2007;27707-20.  Back to cited text no. 8
    
9.
Coulier B. Contribution of US and CT for diagnosis of intraperitoneal focal fat infarction (IFFI): A pictorial review. JBR-BTR 2010;93:171-85.  Back to cited text no. 9
    
10.
Goti F, Hollman R, Steiger R, Lange J. Idiopathic segmental infarction of the greater omentum successfully treated by laparoscopy. Surg Today 2000;30:451-3.  Back to cited text no. 10
    


    Figures

  [Figure 1]MedJDYPatilUniv_2015_8_4_534_160830_f1.jpg, [Figure 2]MedJDYPatilUniv_2015_8_4_534_160830_f2.jpg, [Figure 3]MedJDYPatilUniv_2015_8_4_534_160830_f3.jpg


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