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World Journal ofEmergency

Surgery

BioMed Central

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Published: 29 Octo

World Journal of Eme3:30

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The purpose of this report

is to describe our first

experi-ence with this

condition. Een thou!h the

etiolo!" is un#nown$ we

hi!hli!ht some of the

possible theories. Anal"sis

of some collectie reiews

%&' and our experience with

this patient indicate that the

s"mptoms$ clinical find-

in!s$ preoperatie dia!nosisand mana!ement of this

con-dition are almost

identical$ een in children.

A ()-"ear-

old

woman

presented

to the

emer!enc"

depart-

ment

complaini

n! of ri!ht

lower

abdominal

pain of (

hours of

duration

alon! with

hi!h feer

and nausea

with-out

omitin!.

The

patient had

no

releant

preious

medi-cal

histor".

The pain

started at

the ri!ht

paraumbili

cal and

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World Journal of Emergency Surgery 2008*3:30

subcostal re!ion$ radiatin! down to the ri!ht iliac fossa re!ion.

+h"sical examination reealed normal ital si!ns$ no feer$ no

abdominal distension but a tender abdomen in the ri!ht lower

,uadrant with !uardin! and rebound ten-derness. o mass was

palpable. esults of laborator" stud-ies reealed leucoc"tocis

with a /01 count of 234567 mm&and a 1+ of 2)& m!7L.

0oth$ the plain x-ra"s and the ultrasono!raph" of the abdomen

showed no abnor-malities. o further tests were performed$

and the patient was ta#en to the operatin! room with the

dia!nosis of acute appendicitis after appropriate antibiotic

proph"laxis was administrated.

8ur!er" was performed throu!h a ri!ht pararectal incision in

order to allow a !ood examination of the of the ceco-

http:--###!#.es!org-content-3-+-30

appendicular and surroundin! area. At sur!er"$ the omen-tum

was found to be !rossl" dar# and thic#ened. Adhe-sions

between the !reater omentum and the ri!ht abdominal wall

were seen. 9urther exploration reealed infarction without

torsion of the ri!ht se!ment of the !reater omentum locali:ed

at the inferior ri!ht ,uadrant re!ion in an area of

approximatel" 236 cm3 ;26 cm per 23 cm< ;9i!. 2

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Figure 1

Macroscopicalappearance of teinfarcted area of tegreater omentum foundduring laparotomy foracute appendicitis! /otethe change in color andedema o the omental atarro#s1!

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World Journal of Emergency Surgery 2008*3:30

=istopatholo!ical examination confirmed the dia!nosis of

omental infarction and phle!monous acute appendici-tis. The

histolo!ical examination reealed a reddish infarc-tion of the

fatt" tissue of the !reater omentum. The omentum contained

scattered hemorrha!es and the es-sels were mar#edl"

distended with blood. ;9i!. 3ependin! on the causatie factor$ this clinical problem can be

classified as omental infarction with torsion$ and

http:--###!#.es!org-content-3-+-30

omental infarction without torsion$ commonl" #nown as

idiopathic omental infarction ;Table 2

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Figure "

Micrograp sowing teistological results ofte infarcted omentum!/ote the areas o atnecrosis and li$ueac(ti)echanges! There are alsoscattered acuteinlammator" cells!

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World Journal of Emergency Surgery 2008*3:30 http:--###!#.es!org-content-3-+-30

#able 1$ %lassification of te infarctions of te greater omentum!

Omental infarction without torsion:

Primar" Idiopathic inarction o the greater omentum1

econdar": hernia* h"percoagulabil"* patholog" )ascular* pol"globulia

Omental infarction with torsion:

Primar"econdar": adherences* c"sts* tumor

as preoperatie dia!nosis$ but the appendix is usuall" found to be

macroscopicall" normal either at exploration or at

histopatholo!ical anal"sis %('.

The exact etiolo!" and patho!enesis of this condition is

un#nown. 8ome authors hae su!!ested that con!enitall"

anomalous fra!ile blood suppl" to the ri!ht lower portion of the

!reater omentum renders this re!ion prone to inf-arction %4'.

Other authors %5' su!!est a different embr"-onic ori!in for the

ri!ht side of the !reater omentum with more fra!ile blood essels

which are more susceptible to elon!ation and secondar"

occlusions. 8uch a theor" could explain the hi!h incidence ;@6?ifferentiation betweentorsion and infarction is not of

practical si!nificance as the

mana!ement remains the

same$ i.e. sur!ical resection of

the infarcted omentum$ and it

is the usual treatment when

the dia!nosis is not

established preoperatiel".

Either b" open sur!er" or

laparoscop"$ the rationale for

excision rests on the theo-

retical possibilit" of adhesions

formin! about the infarct$

which could obstruct nearb"

bowel loops.

Idiopathic se!mentalinfarction of the ri!ht sided

!reater omentum should be

considered een in the

presence of acute appendicitis

or other intra abdominal

patholo!ies since it ma" occur

and mimic the basic

patholo!ic condi-tion as an

associated disease.

9urthermore$ een when other

iscera are found to be normal

at exploration$ the omentum

should be inspected forinfarction$ especiall" if free

serosan!uineous peritoneal

fluid is present.

The ph"sical findin!s are ariable but

usuall" there is ten-derness in the ri!ht side

of the abdomen$ predominantl" at the ri!ht

lower ,uadrant. +h"sical examination

usuall" elicits locali:ed tenderness with or

without a palpable BmassB. Temperature isusuall" normal or sli!htl" raised.

Occasionall"$ the /01 count ma" be

eleated. Therefore$ clinicall"$ omental

infarction is difficult to be distin-!uished

from appendicitis$ cholec"stitis$ or adnexal

prob-lems.

8ince it is rarel" dia!nosed before sur!er"$

the ima!in! fea-

tures of omental

resection hae

been seldom

described in the

radiolo!ical

literature.1omputed

tomo!raph" and7or

ultrasound can be

extremel" helpful

in establishin! the

dia!nosis. 0oth

ma" show a well

circumscribed$

ooid or

%onclusionIt is possible that

infarction of

un#nown ori!in

inolin! the

!reater omentum is

more common than

is usuall" thou!ht.

/e emphasi:e that

idiopathic

se!mental infarc-

tion of the !reater

omentum should

be included in the

differential

dia!nosis of an"

patient with ri!ht

sided abdominal

pain$ and

inspection of the

omentum should

be a routine part of

exploration when amore common

cause of abdominal

complaint is not

readil" obious at

operation or een

in the presence of

other intra abdomi-

nal conditions.

%onsentB/ritten informed

consent was

obtained from the

patient for the

publication of this

article and

accompan"in!

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World Journal of Emergency Surgery 2008*3:30 http:--###!#.es!org-content-3-+-30

ima!es. A cop" of the written consent is aailable for reiew

b" the Editor-in-1hief of this Cournal.B

%ompeting interestsThe authors declare that the" hae no competin! interests.

&utors' contributionsL0 wrote the manuscript and participated to sur!ical pro-

cedures and to preoperatie and postoperatie patient

mana!ement$ A participated in manuscript desi!n and

coordination$ G0 participated in literature reiewin! and

patient follow-up$ GG participated in literature reiewin! and

patient follow-up$ E+ participated in literature reiew-in!$ M

participated in literature reiewin!$ M partici-pated in

literature reiewin!$ 90 participated in literature reiewin!$

EL is the 1hief of the 8ur!ical Dnit and partici-pated in

manuscript desi!n.

&c(nowledgementsThis stud" #as partiall" supported b" grants o the Italian ssociation or

Cancer Research IRC 4 5ilan1! uthors than6 the secretar"* 5rs ceto

Roberta* or assistance in preparing the manuscript!

References

2. 7ush P: & case of aemorrage into te greater omentum!The Lancet +89*1)*$28!

3. 7arcia P* /elson T: +rimary segmental infarction of teomentum wit and witout torsion!AmJ Surg+9'3*1",$328(329!

&. ;o C* ;ollmann R* tieger R*

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