Torsion and/or infarction of the greater omentum are rare but well-recognized clinical situations which present as an acute abdomen. The etiology is unknown and speculative. In most cases, the pathology is right sided and clinical presentation consists of an acute or subacute flank pain with mild peritonism usually evoking appendicitis or cholecystitis. Nevertheless, knowledge concerning these two problems can help the surgeon in proper diagnosis and treatment. Since the first report on primary torsion by Eitel in 1899, a few hundred more have been reported and some collective reviews published to date. Recently, ultra sonography and computed tomography have proved to provide sufficiently typical, consistent, and well-recognizable features to avoid unnecessary surgery. In this study, we will present a case diagnosed as primary omental torsion based on computed tomography, which underwent successful conservative management.
Vascular accidents of the omentum including torsion, infarction, and hemorrhage are all rare causes of the acute abdomen. They are usually misdiagnosed in the majority of cases as acute appendicitis, followed by acute cholecystitis. Other differential diagnoses are perforated peptic ulcer, appendicular abscess, pancreatitis, torsion of ovarian cyst, and diverticulitis [
Spontaneous detorsion is an expected possibility [
In this study a case of primary omental torsion, conservatively managed is presented with a review of literature, indicating that unnecesseary surgery can be successfully avoided.
A 74-year-old woman was admitted to hospital with a 4-days history of abdominal pain. The pain started suddenly in the upper abdomen, increased in severity and localized in the epigaster and right upper quadrant. The pain was constant, and associated with nausea, vomiting and back radiation. There was a previous history of diabetes mellitus (type II), ischemic heart disease, and chronic hypertension. On examination, blood pressure was 160/95 mmHg and other vital signs were normal. Abdominal examination revealed generalized guarding and tenderness with major severity and rebound tenderness in the right upper quadrant. Bowel sounds were hypoactive, and there was no abdominal distension. A tender and ill-defined fullness was palpable. Total white blood cell count was 9500/mm3.
Ultrasound (US) examination was performed which revealed a heterogenous echogenic mass in the upper abdomen. No caecal and appendiceal abnormality was identified. Kidneys and hepatobiliary system were also normal.
As the patient's abdominal tenderness persisted the next day, a computed tomography (CT) scan was requested which demonstrated a 12 × 7 cm amorph and solid mass at the site of tenderness in the upper abdomen. It was adherent to the anterior wall of abdomen at the midline (Figure
Axial CT view illustrating the presence of an inflammatory focal fatty mass just under the anterior abdominal wall.
The patient was managed conservatively with oral analgesic and antibiotics. The pain gradually resolved in 2 days and she was discharged after 9 days of hospitalization. Upon review in the outpatient clinic at 1 week, 1 month and 6 months after discharge, the patient remained well. She did not consent to perform CT scan for follow up.
Acute conditions of the omentum including torsion, infarction and hemorrhage are all rare but well-recognized conditions. Omental torsion was first described in the literature by de-Marchetti in 1858 and primary torsion of the omentum by Eitel in 1899 [
Torsion of the omentum is usually segmental and may be idiopathic or secondary to intra-abdominal inflammatory foci, adhesions and internal hernias [
There are several clinical peculiarities of primary segmental omental infarction that have been established. Patients usually present with acute abdominal pain without other gastrointestinal symptoms. They are usually constitutionally well, without fever or leucocytosis. Focal tenderness with varying degrees of peritonism is found on examination. Given that segmental infarction is usually right sided, appendicitis is the usual presumed diagnosis or, rarely, cholecystitis. Since it is such a rare condition, the diagnosis is usually made at surgery, but is occasionally discovered preoperatively during cross-sectional imaging.
In recent years, the correct preoperative diagnosis of omental torsion via US or CT scan has increasingly been reported in the literature [
In this case, regarding the typical clinical manifestations, computed tomography was performed which demonstrated an amorph and solid mass at the site of tenderness in the upper abdomen, adherent to the anterior wall. The heterogenic mass seen on CT scan was corresponded to a focal, well-demarcated area of greater omentum. These findings suggest that clinical symptoms can clearly lead to pathologic diagnosis.
Previously, omental torsion was almost always managed operatively as this condition was usually found unexpectedly during surgery [
In summary, we have reported a case of omental torsion diagnosed by CT scan and successfully managed nonoperatively. These imaging findings are important to recognize because unnecessary surgery may be avoided when the patient's clinical condition remains stable. However, if the diagnosis is uncertain, diagnostic laparoscopy or laparotomy should be performed to confirm the diagnosis and exclude other sinister causes.