Article, Surgery

Primary torsion of omentum: a rare cause of acute abdomen

Case Report

Primary torsion of omentum: a rare cause of acute abdomen

Abstract

In this study, a rare case of primary omental torsion was reported. A 20-year-old man presented with Right lower quadrant pain and nausea. Physical examination revealed abdominal tenderness in the right iliac fossa, but muscular rigidity was not found. Increased white blood cell count (23,400/mL) was noted in the whole blood count. The patient underwent laparotomy with an Initial diagnosis of acute appendicitis. The abdominal exploration revealed a normal appendix and infarcted omentum secondary to torsion on the long axis. The torted and necrotic omentum was resected, and the patient was discharged uneventfully at postoperative second day. Omental tortion should be considered as a possible diagnosis especially when the appendix does not explain the patient’s symptoms during the abdominal exploration.

Torsion of the omentum is a rare cause of acute abdominal pain. A definitive diagnosis is often made by intraoperative exploration, and management of this condition has usually involved resection of the torted omentum [1,2]. Although conservative management has been recommended for selective cases, it should be kept in mind that delayed treatment may also lead to Intra-abdominal abscess, sepsis, and adhesion formation due to late complications [3]. Recent literature data advocates conservative management [4,5], but at times, this approach may lead to a clinical dilemma. Although abdominal computerized tomography makes conservative management possible in an advanced medical center [6], traditional surgical treatment is still valuable as a standard treatment. Excision of the torted omentum sig- nificantly reduces complications such as adhesion and abscess formation [7,8].

A 20-year-old man was admitted to the emergency department with right lower quadrant pain, dizziness, and nausea. His medical history revealed that his complaints began 1 day before his admission. The patient had not experienced any previous abdominal surgery or trauma.

On physical examination, abdominal tenderness was noted in the right iliac fossa, but there was no remarkable muscular rigidity. Increased white blood cell count

(23,400/mL) was noted in the whole blood count. Blood chemistry including renal and Hepatic functions were within normal limits. Abdominal ultrasonography reported edematous and heterogenic tissue planes, which were thought to possibly be omental fatty tissue with minimal to moderately free fluid located in the right lower abdominal quadrant. In addition, hiperecoic and heterogenic tissue folds, presumed to be edematous mesenteric planes, were reported in the same place.

Based on these findings, the patient underwent lapar- otomy with an initial diagnosis of Perforated appendicitis. At laparotomy, a moderate amount of free serosanguinous fluid was found in the right paracolic gutter, but the appendix was normal. After a thorough examination of the abdomen, a necrotic, torted omentum was observed (Fig. 1). The omentum was found rotated, on the long axis, 4 to 5 times in a clockwise manner. The rest of the abdominal organs were normal. The torted and necrotic omental structure was resected (Fig. 2), and an appendectomy was also performed. The pathological examination of the resected material revealed hemorrhagic necrotic fatty tissue. The patient’s postoperative recovery was uneventful, and he was dis- charged 2 days later.

Omental torsion is a kind of volvulus created by the rotation of the omentum on its long axis, which can lead to

Fig. 1 Intraoperative appearance of twisted omentum, The omentum was found torted on its long axis, 4 to 5 times in a clockwise manner.

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115.e6 Case Report

especially when a precise diagnosis cannot be ascertained. Recent studies have demonstrated that torsion of the omentum can be correctly diagnosed and treated laparosco- pically [13,16,17].

Omental tortion should be considered and should be included in the differential diagnosis when a patient is given an abdominal exploration for acute appendicitis, and the examination shows a normal appendix with seroHemorrhagic fluid in the peritoneal cavity [18].

Fig. 2 Twisted specimen of the primary omental torsion. The infarcted portion was congested and hemorrhagic.

tissue ischemia and necrosis. It usually affects adults between the ages of 40 and 50 years and children between 9 and 16 years old. The male/female ratio is 1.5:1 [9]. The incidence is very rare especially in childhood and decreases to 0.024% in children undergoing laparotomy or laparo- scopy for suspected appendicitis [10,11]. Although it can occur on both sides of the abdomen, a right-sided omental torsion is much more common than a left-sided one. [12,13]. Omental torsion may be classified as either primary, when any obvious cause is not found, or more commonly secondary. The latter form is mostly associated with intra-Abdominal pathology such as omental cyst, tumor, hernia, or adhesion [7].

On the other hand, primary omental torsion mostly results from Benign conditions such as obesity, the presentation of bifid, accessory or tongue-like omental structures, and redundant omental veins [14].

The primary symptom associated with omental torsion is pain, which is frequently localized in the right lower quadrant of the abdomen. The onset of pain is usually sudden and does not radiate to the abdominal wall [12,15]. In many cases, the pain localizes in the right lower quadrant and reveals signs of peritoneal irritation, which mimic acute appendicitis or cholecystitis. Bowel movements are usually normal, and nausea and vomiting are rare [1]. A thorough blood workup reveals normal values in many cases. A computerized tomography scan and ultrasound can be used for preoperative diagnosis, but these 2 modalities have low sensitivity and specificity [3,7,8].

It is difficult to diagnose the torsion of omentum before performing an operation. A preoperative diagnosis can be achieved by keeping the disease in mind. Generally, a laparotomy becomes inevitable especially when the diag- nosis is not clear. When a laparotomy is planned, a midline abdominal incision makes the exploration and diagnosis easier than McBurney or any infraumbilical incision,

Ozgur Albuz MD Nail Ersoz MD Zafer Kilbas MD

Ismail Hakki Ozerhan MD

Ali Harlak MD Ozcan Altinel MD Taner Yigit MD

Department of General Surgery Gulhane Military Medical Academy

Ankara 06018, Turkey E-mail address: [email protected]

doi:10.1016/j.ajem.2009.03.013

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Case Report 115.e7

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