|Year : 2015 | Volume
| Issue : 6 | Page : 836-839
Torsion of lobular capillary hemangioma of greater omentum: A rare cause of acute abdomen
Pandarinath Audi, Dilip Amonkar, Mervyn Correia, Pranav Nagarsenkar, Osborne Vaz
Department of Surgery, Goa Medical College, Bambolim, Goa, India
|Date of Web Publication||19-Nov-2015|
Flat No. A-102, Atmaram Enclave, Near Sateri temple, Khorlim, Mapusa, Goa - 403 507
Source of Support: None, Conflict of Interest: None
Metastatic tumors of the omentum are common. In contrast, the primary tumors of the omentum are very rare. Primary benign tumors of the omentum include lipomas, myxomas, and desmoid tumors. Primary malignant tumors include leiomyosarcoma, liposarcoma, etc. We report here a case of a 32-year-old female who presented to our emergency department with pain in lower abdomen of 1-day duration. The patient underwent laparotomy and was found to have an irregular mass with bosselated surface arising from the omentum that had caused torsion of the omentum. Histopathology confirmed it to be a lobular capillary hemangioma (LCH) of greater omentum. The postoperative course was uneventful, and she has followed up for last 6 months without any recurrence. There is not yet a single reported case of LCH of omentum.
Keywords: Gastrointestinal capillary hemangioma, lobular capillary hemangioma, omental torsion
|How to cite this article:|
Audi P, Amonkar D, Correia M, Nagarsenkar P, Vaz O. Torsion of lobular capillary hemangioma of greater omentum: A rare cause of acute abdomen. Med J DY Patil Univ 2015;8:836-9
|How to cite this URL:|
Audi P, Amonkar D, Correia M, Nagarsenkar P, Vaz O. Torsion of lobular capillary hemangioma of greater omentum: A rare cause of acute abdomen. Med J DY Patil Univ [serial online] 2015 [cited 2020 Oct 24];8:836-9. Available from: https://www.mjdrdypu.org/text.asp?2015/8/6/836/169926
| Introduction|| |
Metastatic tumors of the greater omentum are common. In contrast, the primary tumors of the greater omentum are very rare. , These tumors can cause torsion of the greater omentum, which can result in acute abdominal pain. Torsion of omentum causes twisting along its long axis resulting in impaired blood supply. Torsion of omentum is rarely diagnosed preoperatively and can lead to clinical deterioration of the patient if missed. 
Lobular capillary hemangioma (LCH) was first described by Poncet and Dor in 1897 using the term Botryomycose humaine,  subsequently referred to as pyogenic granuloma, granulation type hemangioma. The term LCH has gained favor since 1980s. , These tumors are diagnosed by histopathology and immunohistochemistry. The optimal management is by complete excision.
| Case Report|| |
PM, a 32-year-old female, presented to the emergency department with complaints of pain in left lower abdomen of 1-day associated with two episodes of vomiting. The patient was para-1 and there was history of use of oral contraceptive pills (OCP).
On examination: Pulse - 100/min, there was tenderness in the region of hypogastrium and left iliac fossa.
There was no evidence of any capillary hemangioma on the skin.
PV and PR examination done were normal.
- Total white blood cell count - 9900/cumm.
- Urine examination was normal.
- Renal function tests were normal.
- X-ray abdomen was normal.
Abdominal and pelvic ultrasound showed free fluid in pelvis with a mass in lower abdomen. Contrast-enhanced computed tomography (CECT) scan of abdomen [Figure 1] and [Figure 2] showed a large, well-defined soft tissue mass in the lower abdomen extending into the pelvis on the left side measuring 8.4 cm × 6.6 cm × 9.4 cm in size showing contrast enhancement. The mass was seen to displace the adjacent bowel loops laterally and to abut the fundus of the uterus and broad ligament on the left. There were a few vessels noted along the left lateral aspect of the mass, which were seen to supply the mass.
|Figure 1: Axial section showing an intraperitoneal mass that enhances contrast displacing the adjacent bowel loops|
Click here to view
|Figure 2: Sagittal section showing the intact fat planes between the mass and the urinary bladder|
Click here to view
The differential diagnosis based on the CECT scan was that of a mesenteric mass, which had undergone torsion. Also, a rare possibility of a left broad ligament fibroid undergoing torsion was to be considered.
The patient underwent an emergency laparotomy. It was found that there was a mass arising from the omentum, irregular in shape with bosselated surface that had undergone torsion ([Figure 3] - Omentectomy specimen).
|Figure 3: Intraoperative image of an omental mass which has undergone torsion|
Click here to view
Complete excision of the tumor was done with partial omentectomy.
Histopathology report from Tata Memorial Centre, Mumbai showed it to be LCH ([Figure 4] - Low power microscopy and [Figure 5] - High power microscopy).
On immunohistochemistry, CD-34 highlighted the vascular channels. Stains for S-100, C-kit, smooth muscle actin, and DOG-1 were negative.
The patient has followed up for last 6 months and is asymptomatic without any recurrence.
| Discussion|| |
Primary tumors of the greater omentum are uncommon. They could be benign or malignant. Benign tumors of the omentum include gastrointestinal (GI) stromal tumors (which have malignant potential depending on tumor size, mitotic activity, cellularity, and invasive growth), lipomas, myxomas, and desmoids tumors. Because the omentum is derived from the mesoderm, primary malignant tumors of the omentum are considered sarcomas.  The most common primary malignant lesions are leiomyosarcomas, hemangiopericytomas and fibrosarcomas, and liposarcomas.  Metastatic tumors involving the omentum are quite common. Metastatic ovarian tumors have a high preponderance of omental involvement. Malignant tumors of the stomach, small intestine, colon, pancreas, biliary tract, and kidneys may also metastasize to the omentum. In an advanced stage, the omentum becomes replaced by the metastatic tumor resulting in the descriptive term "omental cake." 
The omental tumors can cause torsion of omentum and present with acute abdominal pain. Torsion of omentum causes twisting along its long axis resulting in impaired blood supply. 
Omental torsion can be primary or secondary. Primary or idiopathic omental torsion is a rare condition that occurs because a mobile, thickened segment of omentum rotates around a proximal fixed point in the absence of any associated or secondary intra-abdominal pathology. Secondary torsion is more common and is associated with abdominal pathology such as inguinal hernia (most common), tumors, cysts, internal or external herniation, foci of intra-abdominal inflammation, and postsurgical wound or scarring. ,
The torsion of the omentum is usually in clockwise direction where the venous return is compromised and distal omentum becomes congested and edematous. Hemorrhagic extravasation leads to an accumulation of serosanguinous fluid in the peritoneal cavity then acute hemorrhagic infarction and omental necrosis due to arterial occlusion. ,
Clinically, omental torsion presents with constant pain in the abdomen; the majority in the right lower quadrant.  Although omental torsion is rarely diagnosed preoperatively, knowledge of the pathology is important to the surgeon because it mimics the common causes of acute abdominal pain.  Management is exploratory laparotomy with surgical resection of the affected segment. Laparoscopy can be considered as the first choice procedure if diagnosis is made preoperatively. , In our case, since the diagnosis of omental torsion was not made preoperatively and since in our hospital setup, laparoscopy is not available at emergency level and is done only on elective basis, laparoscopy was not considered.
There is not yet a single reported case of LCH of omentum in literature so far. The cutaneous LCH usually occurs in children or young adults as a solitary glistening red papule or nodule that is prone to bleeding and ulceration. It has been reported in all parts of skin and mucus membrane including vulva, scrotum, and penis. , Oral lesions are more common on the gingiva, lips, and tongue. Several cases have been reported in the nasal cavity. LCH arising from the nasal septum may be associated with nasal intubation as the triggering agent. LCH is also known to occur at various other sites such as cornea, conjunctiva, central nervous system, and internal vasculature.
The first clear reports of GI LCH were attributed to Payson et al. in 1967.  A small number of GI lesions have since been noted predominantly in colon, ileum, and esophagus. Also, there are case reports of gastric LCH presenting with chronic malena and iron deficiency anemia.  The GI lesions are typically pedunculated or semi-pedunculated and are less frequently sessile.
Although GI lesions are typically solitary, multiple (>10) GI lesions have been reported in a single patient.  These lesions were detected in the sigmoid colon of a patient presenting with diarrhea and occult blood positive stool.
The precise mechanism for the development of LCH is unknown. Trauma, hormonal influences, virus, underlying microscopic A-V malformation, production of angiogenic growth factors, and cytogenetic abnormalities have all been postulated to play a role. LCH often occurs in pregnancy (or rarely with OCP usage) particularly on the gingival or elsewhere in the oral mucosa and then is termed the "pregnancy tumor."
Clinical presentation of GI LCH depends upon their site. Esophageal lesions present with chest discomfort,  dysphagia, ,, hematemesis  or may be incidentally discovered. Gastric LCH present with chronic malena  and iron deficiency anemia. Duodenal lesions have presented with anemia unresponsive to iron therapy  or with overt upper GI bleeding. Small bowel lesions have presented with malena, anemia, and intussusception.  Colonic lesion have presented with malena,  hematochezia,  and diarrhea. 
Histopathologically, LCH are characterized by capillary sized vessels arranged in lobules. On immunohistochemistry, Von Willebrand factor and CD34 are positive in lining endothelial cells.
| References|| |
Ishida H, Ishida J. Primary tumours of the greater omentum. Eur Radiol 1998;8:1598-601.
Miyazawa M, Naritaka Y, Miyaki A, Asaka S, Isohata N, Yamaguchi K, et al.
A low-grade myofibroblastic sarcoma in the abdominal cavity. Anticancer Res 2011;31:2989-94.
Parr NJ, Crosbie RB. Intermittent omental torsion - An unusual cause of recurrent abdominal pain? Postgrad Med J 1989; 65:114-5.
Poncet A, Dor L. Botryomycose humaine. Rec Chir 1897;18: 996-1003.
Harris MN, Desai R, Chuang TY, Hood AF, Mirowski GW. Lobular capillary hemangiomas: An epidemiologic report, with emphasis on cutaneous lesions. J Am Acad Dermatol 2000;42:1012-6.
Weiss SW, Goldblum JR, editors. Enzinger & Weiss's Soft Tissue Tumors. 5 th
ed., Ch. 22. Philadelphia: Mosby Elsevier; 2008. p. 633-79.
Schwartz RW, Reames M, McGrath PC, Letton RW, Appleby G, Kenady DE. Primary solid neoplasms of the greater omentum. Surgery 1991;109:543-9.
Borgaonkar V, Deshpande S, Rathod M, Khan I. Primary omental torsion is a diagnostic challenge in acute abdomen - A case report and literature review. Indian J Surg 2013;75:255-7.
Kargar S, Fallahnejad R. Primary torsion of lesser sac omentum. Internet J Surg 2006;7:2. doi: 10.5580/571.
Breunung N, Strauss P. A diagnostic challenge: Primary omental torsion and literature review - A case report. World J Emerg Surg 2009;4:40.
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.
Danikas D, Theodorou S, Espinel J, Schneider C. Laparoscopic treatment of two patients with omental infarction mimicking acute appendicitis. JSLS 2001;5:73-5.
Leboit PE, Burg G, Weedon D, Sarasin A, editors. World Health Organization Classification of Tumour. Pathology & Genetics of Skin Tumours. Lyon: IARC Press; 2006. p. 229-50.
Payson BA, Karpas CM, Exelby P. Intussusception due to pyogenic granuloma of ileum. N Y State J Med 1967;67:2135-8.
Antonio Quiros J, Van Dam J, Longacre T, Banerjee S. Gastric pyogenic granuloma. Gastroenterol Hepatol (N Y) 2007;3:850-4.
Chen TC, Lien JM, Ng KF, Lin CJ, Ho YP, Chen CM. Multiple pyogenic granulomas in sigmoid colon. Gastrointest Endosc 1999;49:257-9.
Okada N, Matsumoto T, Kurahara K, Kanamoto K, Fukuda T, Okada Y, et al.
Pyogenic granuloma of the esophagus treated by endoscopic removal. Endoscopy 2003;35:375.
van Eeden S, Offerhaus GJ, Morsink FH, van Rees BP, Busch OR, van Noesel CJ. Pyogenic granuloma: An unrecognized cause of gastrointestinal bleeding. Virchows Arch 2004;444:590-3.
Craig RM, Carlson S, Nordbrock HA, Yokoo H. Pyogenic granuloma in Barrett's esophagus mimicking esophageal carcinoma. Gastroenterology 1995;108:1894-6.
Manabe T, Goto H, Enya M, Nandate Y, Mizuno S, Kanematsu M, et al.
A case of pyogenic granuloma in the cervical esophagus. Nihon Shokakibyo Gakkai Zasshi 1998;95:230-2.
Kusakabe A, Kato H, Hayashi K, Igami T, Hasegawa H, Tsuzuki T, et al.
Pyogenic granuloma of the stomach successfully treated by endoscopic resection after transarterial embolization of the feeding artery. J Gastroenterol 2005;40:530-5.
Hirakawa K, Aoyagi K, Yao T, Hizawa K, Kido H, Fujishima M. A case of pyogenic granuloma in the duodenum: Successful treatment by endoscopic snare polypectomy. Gastrointest Endosc 1998;47:538-40.
Yao T, Nagai E, Utsunomiya T, Tsuneyoshi M. An intestinal counterpart of pyogenic granuloma of the skin. A newly proposed entity. Am J Surg Pathol 1995;19:1054-60.
Carmen González-Vela M, Fernando Val-Bernal J, Francisca Garijo M, García-Suárez C. Pyogenic granuloma of the sigmoid colon. Ann Diagn Pathol 2005;9:106-9.
[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5]