Omental Infarction due to Omental Torsion

Diagnostic challenge: Secondary omental torsion misdiagnosed as acute appendicitis-A case report

This case presents a diagnostic challenge in a 28-year-old male initially evaluated for severe abdominal pain, vomiting, and constipation, leading to the presumption of post-appendectomy complications. Clinical examination revealed abdominal distension, tenderness, and signs of peritonism, along with a reducible inguinal hernia. On subsequent CT scan, a large, inflamed area of omentum localized to the right abdomen extending up to the defect in the inguinal region with mild ascites was revealed. Upon exploration, it was discovered that the patient's initial surgery had focused solely on an appendix deemed mildly inflamed by the operating surgeon, while a concurrent diagnosis of secondary omental torsion was missed. This oversight underscores the challenges in diagnosing abdominal pathologies, with the initial misdiagnosis leading to ongoing patient distress. Meticulous adhesiolysis and omentectomy were performed, resulting in the resolution of the patient's symptoms.

Omental torsion: diagnostic challenge in patients with sclerosing cholangitis and inflammatory bowel disease - case report

Introduction and importance

The omentum appears as an apron-like extension of the peritoneum.

Case presentation

A 30-year-old male patient, presented to the emergency department with the chief complaints of acute nonradiating pain localized in the right-side abdomen for the past 3 days. The patient had a past medical history of sclerosing cholangitis (SC) with inflammatory bowel disease (IBD). The patient reported the pain as persistent, pressure-like, and moderate. The patient also had a low-grade fever and nausea at the time of admission. On examination, the vital signs were found as normal. The patient reported that the abdominal pain gets exacerbated after the meals, and increase in physical activity and movement. Due to the patient's complaints and history of SC and IBD, these were considered as the possible diagnosis. After the diagnostic procedures, the patient was finally diagnosed with OT.

Clinical discussion

This report presents a case of a patient suffering from omental torsion having history of SC and IBD. During the laparoscopic procedure, the diagnosis of omental torsion was confirmed. To our knowledge, no case report of omental torsion with IBD and SC is published in the literature.

Conclusion

This seems to be a major diagnostic challenge as patients with IBD almost resembles the same clinical signs and symptoms as in the omental torsion. The possibility of misdiagnosis and delayed diagnosis could result in the unfavorable outcome. Therefore, the healthcare fraternities are advised to include the rare diseases such as OT as the differential diagnosis.

Post-myomectomy omental infarction: a case report

BACKGROUND

Omental Infarction (OI) is uncommon and mimics common causes of acute abdomen. It is important to differentiate it from other abdominal conditions that require emergency management. It was first reported in literature in 1896 and about 400 cases have been reported till date.

CASE PRESENTATION

We reported on a 41 year-old Para 0⁺⁰ Ibo house wife who presented with 10 years history of supra-pubic mass and five months history of excessive menstrual flow. After physical examination, a diagnosis of symptomatic uterine fibroid was made. She had myomectomy and the raw surface created after the excision of the myomas was covered with omentum. Wound infection developed on the 8th post-operative day leading to a wound breakdown and later partial extrusion of infarcted omental tissue through the dehisced wound. During re-exploration, the infarcted omental tissue was extracted and the residual abdominal abscess was drained. Surgical site wound infection occurred on the 3rd day after re-operation and a sub-acute intestinal obstruction developed on the 4th day thereafter which responded to conservative management.

CONCLUSION

Careful surgical technique is imperative when utilizing the omentum for reconstructive abdominal surgery. Torsion of the omentum and creation of excess tension while using the omentum for reconstructive procedures should be avoided and increase awareness of this uncommon disease condition by the surgeon is also important. This case is to report a rare finding of omental infarction following myomectomy.

Laparoscopic Management of Primary Omental Torsion

Primary omental torsion is an unusual condition, known for its rarity and for the particularity of being intraoperatively diagnosed, in nearly all cases. At the clinical evaluation, this pathology commonly mimics other etiologies of acute abdomen. Hemoperitoneum and necrosis of the omentum are rarely associated with the omental torsion, but when the association is found, then it means that the vascular injuries are irreversible and the required surgical procedure may be far more complex than simple devolvulus. In search of the treatment of choice, laparoscopy proved its effectiveness as a diagnostic and therapeutic tool, while the open surgery approach can be described in many cases as being too invasive. A 37-year-old female patient presented with the generic symptoms of acute appendicitis. Surgical treatment was initiated. During laparoscopy, the abdomen was attentively explored, highlighting the presence of a twisted omentum with hemoperitoneum and necrosis. Omental excision and peritoneal drainage were performed. The evolution was favorable. Another check-up was done at 6 months postoperatively, displaying no signs or symptoms of relapse.

Intraperitoneal focal fat infarction: the great mimicker in the acute setting

The term intraperitoneal focal fat infarction (IFFI) includes various self-limiting clinical conditions that are caused by focal fatty tissue necrosis. Most of the cases of IFFI concern torsion or infarction of the greater omentum or the epiploic appendages. However, although rarely, perigastric ligaments can also undergo torsion also leading to fat infarction. IFFI clinically may mimic other pathologies, such as acute appendicitis or diverticulitis, making their clinical diagnosis a challenge. Ultrasound (US) and computed tomography (CT) have a high sensitivity and specificity for the diagnosis of IFFI excluding other pathologies, and in most cases, the clinical evolution is spontaneously favorable, thus helping to reduce the need for unnecessary surgical intervention. We review cases with IFFI in order to identify specific involvement patterns. Cases of epiploic appendages reported to an acute, subacute, and more chronic phase in order to present the self-limiting nature of this entity and the resultant absorption. We also present cases with falciform ligament infarction, as well as primary ("whirl sign" on CT due to greater omentum torsion) and secondary omental infarctions. The aim of this pictorial review is not only to extensively explore the imaging findings of IFFI but to also describe the clinical presentation and pathophysiology of the prementioned conditions.