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CASE REPORT
Year : 2015  |  Volume : 4  |  Issue : 1  |  Page : 50-52

Torsion omentum mimicking appendicitis: A rare cause of pain abdomen


1 Department of General Surgery, King George Hospital, Visakhapatnam, Andhra Pradesh, India
2 Department of General Surgery, Andhra Medical College, Visakhapatnam, Andhra Pradesh, India

Date of Web Publication16-Mar-2015

Correspondence Address:
Dr. Srinubabu Kollu
Department of General Surgery, Andhra Medical College, Visakhapatnam, Andhra Pradesh
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/2277-8632.153326

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  Abstract 

Omental torsion is a rare cause of acute abdomen. It usually presents with acute onset right-sided abdominal pain. The most common risk factors are adult male between 40 and 50 years of age and obesity. Clinical diagnosis is challenging and difficult to differentiate from more common clinical pathologies such as acute appendicitis and acute cholecystitis. Transabdominal imaging such as ultrasonography and computed tomography are useful showing typical whirl pattern. Advocated management is surgical excision of torted omentum. Herein, we report a case of primary omental torsion in an adult and a review of current literature. The diagnosis was incidental when patient was undertaken for laparoscopic appendectomy. This case not only highlights the importance of considering omental torsion in the differential diagnosis of right-sided acute abdominal pain but also endorses the changing practice to the laparoscopic approach for management of right-sided abdominal pain.

Keywords: Abdominal pain, omental torsion, laparoscopy


How to cite this article:
Konkena JR, Gunta SR, Kollu S, Neelam P. Torsion omentum mimicking appendicitis: A rare cause of pain abdomen. J NTR Univ Health Sci 2015;4:50-2

How to cite this URL:
Konkena JR, Gunta SR, Kollu S, Neelam P. Torsion omentum mimicking appendicitis: A rare cause of pain abdomen. J NTR Univ Health Sci [serial online] 2015 [cited 2019 Dec 16];4:50-2. Available from: http://www.jdrntruhs.org/text.asp?2015/4/1/50/153326


  Introduction Top


Omental torsion is a rare condition. Sudden onset right-sided abdominal pain is typical presenting complaint, and therefore, clinical differentiation from more common right-sided pathologies such as acute appendicitis and acute cholecystitis is very difficult. Omental torsion has an incidence of 0.0016-0.37% when compared with appendicitis (ratio of <4 cases/1000 appendicitis). [1]

This report describes an interesting case of omental torsion in an adult male where the diagnosis was made while performing laparoscopic appendicectomy.


  Case Report Top


A 24-year-old male patient has presented with pain in the right upper abdomen, vomiting and fever of 2 days duration. Examination of the abdomen revealed tenderness in the right upper abdomen. Complete blood picture showed the leukocytosis with predominant neutrophilia and total white blood cell count of 22,000/cc. Ultrasonography of the abdomen showed evidence of inflammatory changes with thickened fat and trace of fluid with a mildly thickened appendix measuring 5.5 mm in the sub hepatic region, suggestive of sub hepatic acute appendicitis with perifocal inflammatory phlegmon.

At laparoscopy, sub hepatic appendix with mild inflammation was noted, and appendicectomy was done. However, the mild inflammation of the appendix could not explain the severity of the pain abdomen and hence the sub hepatic area was further explored. Surprisingly, a bit of omentum was found to be strangulated due to torsion around the axis of its attachment to the transverse colon [Figure 1], [Figure 2], [Figure 3]. The strangulated bit of omentum was excised. Postoperative period was uneventful.
Figure 1: Torted omentum

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Figure 2: Gangrenous omentum

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Figure 3: Appendicular stump

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  Discussion Top


Omental torsion around its long axis causing vascular compromise is a rare cause of acute abdomen. Factors predisposing to primary omental torsion, which occurs in the absence of associated pathology include anatomical malformation of the omentum such as a bifid omentum or tongue-like omental projections, local variations in omental fat distribution, particularly in obese patients, and constitutive anomalies of the omental blood supply or pedicle formation. In this regard, the omental veins are larger and more tortuous than the arteries, allowing venous kinking and offering a fixation point around which an omental segment can twist. [2] Secondary omental torsion occurs in association with intra-abdominal pathology such as adhesions, omental cyst, hernia, or tumors.

Primary omental torsion has been reported being more common in adults, with a peak age between 40 and 50 years, two-thirds of whom are male. [3]

Reported literature also shows that most cases present with sudden onset right-sided abdominal pain with localized tenderness and/or guarding mimicking acute appendicitis. This corresponds to common involvement of right-side of omentum which is larger, longer and more mobile than the left side, making it prone to torsion. [4] Features such as nausea, vomiting, fever and leukocytosis are unusual. Traditionally, the diagnosis of omental torsion was made intraoperatively. However, with changing trends in management of acute abdomen by frequent use of abdominal computed tomography (CT) scanning, preoperative diagnosis of omental torsion has increased significantly. Typical CT findings include focal mass of fat density showing streaks in a whirling pattern, which may be associated with little thickening of adjacent bowel wall and presence of serosanguinous fluid. [5] A similar whirling pattern may be seen in small bowel volvulus, but it is usually associated with small bowel obstruction and is centrally located in the mesentery. Traditional management has been resection of torted segment of omentum. [6]


  Conclusion Top


Omental torsion was an incidental finding in the case reported. As ultrasonography was suggestive of acute appendicitis, we opted for laparoscopic appendicectomy. Laparoscopy proved exceptionally useful in detecting torted omentum. Therefore, in view of the experience and current literature, it is recommended that laparoscopy should be the preferred surgical method of management of right-sided abdominal pain.

 
  References Top

1.
Pinedo-Onofre JA, Guevara-Torres L. Omental torsion. An acute abdomen etiology. Gac Med Mex 2007;143:17-20.  Back to cited text no. 1
    
2.
Liebermann-Meffert D. The greater omentum. Anatomy, embryology, and surgical applications. Surg Clin North Am 2000;80:275-93, xii.  Back to cited text no. 2
    
3.
Al-Husaini H, Onime A, Oluwole SF. Primary torsion of the greater omentum. J Natl Med Assoc 2000;92:306-8.  Back to cited text no. 3
    
4.
Altemeier WA, Holzer CE. Primary torsion of the omentum. Surgery 1946;20:810-9.  Back to cited text no. 4
[PUBMED]    
5.
Naffaa LN, Shabb NS, Haddad MC. CT findings of omental torsion and infarction: Case report and review of the literature. Clin Imaging 2003;27:116-8.  Back to cited text no. 5
    
6.
Saraç AM, Yegen C, Aktan AO, Yalin R. Primary torsion of the omentum mimicking acute appendicitis: Report of a case. Surg Today 1997;27:251-3.  Back to cited text no. 6
    


    Figures

  [Figure 1], [Figure 2], [Figure 3]



 

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Abstract
Introduction
Case Report
Discussion
Conclusion
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