Saudi Journal of Gastroenterology

CASE REPORT
Year
: 2007  |  Volume : 13  |  Issue : 3  |  Page : 144--146

Primary omental torsion: A rare cause of acute abdomen


Tariq Ibrahim Al Tokhais, Areej Abdullah Bokhari, Osman Hassan Noureldin 
 Division of General Surgery, Department of Surgery, King Khalid University Hospital, Riyadha, Saudi Arabia

Correspondence Address:
Tariq Ibrahim Al Tokhais
P.O. Box - 17714, Riyadh - 11494
Saudi Arabia

Abstract

Torsion of the greater omentum is a rare condition with symptoms resemble those of acute appendicitis and is infrequently diagnosed preoperatively. Treatment is surgical excision. Laparoscopic approach is an excellent diagnostic and therapeutic tool.



How to cite this article:
Al Tokhais TI, Bokhari AA, Noureldin OH. Primary omental torsion: A rare cause of acute abdomen.Saudi J Gastroenterol 2007;13:144-146


How to cite this URL:
Al Tokhais TI, Bokhari AA, Noureldin OH. Primary omental torsion: A rare cause of acute abdomen. Saudi J Gastroenterol [serial online] 2007 [cited 2020 Jan 21 ];13:144-146
Available from: http://www.saudijgastro.com/text.asp?2007/13/3/144/33469


Full Text

Torsion of the omentum is a rare cause of acute abdomen. The diagnosis is usually made with the help of laparotomy for suspected appendicitis. In 1899, Eittel first described primary omental torsion with no underlying pathology. [1] We present a patient with torsion of the greater omentum without any obvious reason.

 Case Report



A 34 year-old Saudi gentleman presented to the Emergency Department at King Khalid University Hospital complaining of dull abdominal pain for five days. The pain started suddenly around the umbilicus with no radiation. It was constant, aggravated by movement, relieved by rest and associated with nausea and constipation but no vomiting or fever. No other remarkable symptoms and no past surgical history were noted. On examination, he was afebrile with stable vital signs. Body mass index (BMI) was 28.9. Abdomen was tender in the right iliac fossa with rebound tenderness while bowel sounds were normal. Digital rectal examination revealed an empty rectum with no masses or tenderness. Baseline blood investigations were normal (including white cell count, urea, creatinin and electrolytes). Plain abdominal X-ray revealed dilated small bowel loops. He tested positive for hepatitis B virus (HBV) and showed glucose-6-phosphatase deficiency (G6PD).

Acute appendicitis was suspected clinically, so surgery was indicated. Operative findings were grossly normal-looking appendix and bowel, with tongue-like, gangrenous and torted omentum. Hence, excision of the involved omentum and appendicectomy were done. The procedure was done through open Gridiron incision because laparascopic appendectomy is not the standard technique in our hospital. The patient made an uneventful recovery.

Histopathology showed contracted fibrosed appendix with no signs of acute inflammation [Figure 1] and the omentum showed focal areas of infarction and necrosis consistent with torsion [Figure 2].

 Discussion



Torsion of the greater omentum is a rare condition and is infrequently diagnosed preoperatively. [2] It mainly affects young and middle-aged women. [3] It has also been described in children above the age of four years and found in a 17-week pregnant lady. [4],[5] Kimber et al. [6] reviewed over 8000 cases of appendicectomies, quoting omental torsion as being about one in every 600 appendectomies. Patients commonly present with right iliac fossa pain resembling the pain associated with appendicitis, but often lacking the associated gastrointestinal symptoms of nausea, vomiting or anorexia. [7]

The mechanics of torsion appear to be twofold: firstly the presence of a bulky mass of tissue that may be fixed at a point, and secondly a narrow neck to twist around. The pathological processes are those of any torsion. Initially the omentum becomes congested due to obstruction of venous return, inflammation develops with adhesion formation and finally, necrosis occurs due to venous and arterial obstruction. [2],[8] Torsion leads to omental infarction although, omental infarction may be present without signs of torsion at surgery. [9],[10],[11] Possible factors associated with primary torsion of the omentum are obesity and anatomical variations such as tongue-like projections, bifid or accessory omentum and abnormally redundant omental veins. [12]

Secondary torsion usually occurs in association with intraabdominal pathology such as hernia, tumor, cyst or adhesions. [2],[9] Predisposing factors for primary or secondary torsion are similar including sudden increase in intraabdominal pressure following heavy meals, heavy exertion, change in the body position, coughing or sneezing and possibly the use of occupational vibrating tools. [13],[14] Our case had two risks factors-he was overweight and the involved omentum was a tongue-like projection.

Many diagnostic modalities have been tried to accurately diagnose acute appendicitis. Ultrasound is operator-dependent and the results of multicenter trials are disappointing. However, excellent results can be obtained if the investigation is restricted to a few specialists. [15] Use of computed tomographic (CT) scans in general, reduced the rate of negative appendectomy but does not appear to be efficacious in males. [16] Diagnostic imaging with ultrasonography and CT scan can be useful for torsion of omentum but is not very reliable. The classic findings are a whirled appearance and diffuse streaking of the greater omentum with a focal mass of fat density showing streaks in a whirling pattern. [2],[8],[17]

Although conservative treatment was reported, [18] the traditional treatment was excision as this may significantly improve recovery by reducing the frequency of complications, namely adhesion formation and sepsis. [2],[8] The presence of a serous, bloody exudate with a normal ileocecal appendix requires complete examination of the omentum and the whole abdominal cavity. The examination can be difficult through a McBurney incision or any infraumbilical incision.

The use of laparoscopy has become widespread among surgeons and is a highly valuable diagnostic and therapeutic tool. [19] In conclusion, torsion of the omentum is difficult to diagnose preoperatively and is usually detected during laparotomy for acute abdomen. Performance of laparoscopy as a minimally invasive surgery can be useful for both diagnosis and treatment of this uncommon condition.

References

1Eittel GG. Rare omental torsion. NY Med Rec 1899;55:715-6.
2Itinteang T, van Gelderen WF, Irwin RJ. Omental whirl: Torsion of greater omentum. ANZ J Surg 2004;74:702-3.
3Kimber CP, Westmore P, Huston JM, Kelly JH. Primary omental torsion in children. J Pediatr Child Health 1996;32:22-4.
4Adams JT. Primary torsion of the omentum. Am J Surg 1973;126:102-5.
5Stachwics N, Czekierdowski A. Omental torsion in pregnant woman. Wiad Lek 2000;53:109-11.
6Kimber CP, Westmore P, Hutson JM, Kelly JH. Primary omental torsion in children. J Paediatr Child Health 1996;32:22-4.
7Chew DK, Holgersen LO, Friedman D. Primary omental torsion in children. J Pediatr Surg 1995;30:816-7.
8Naffaa LN, Shabb NS, Haddad MC. CT findings of omental torsion and infarction. Clin Imaging 2003;27:116-8.
9Schnur PL, McIbrath DC, Carney JA, Whittaker LD. Segmental infarction of the greater omentum. Mayo Clin Proc 1972;47:751-5.
10Naraynsingh KH, Barrow R, Raju GC, Manmohansingh LU. Segmental infarction of the omentum: Diagnosis by ultrasound. Postgrad Med J 1985;61:651-2.
11Vertuno LL, Dan JR, Wood W. Segmental infarction of the omentum: A cause of the semi-acute abdomen. Am J Gastroenterol 1980;74:443-6.
12Al-Husaini H, Onime A, Oluwole SF. Primary torsion of the greater omentum. J Natl Med Assoc 2000;92:306-8.
13Leitner MJ, Jordan CG, Spinner MH, Reese EC. Torsion, infarction and hemorrhage of the omentum as a cause of acute abdominal distress. Ann Surg 1952;135:103-10.
14Shields PG, Chase KH. Primary torsion of the omentum in a jackhammer operator: Another vibration-related injury. J Occup Med 1988;30:892-4.
15Obermaier R, Benz S, Asgharnia M, Kirchner R, Hopt UT. Value of ultrasound in the diagnosis of acute appendicitis: Interesting aspects. Eur J Med Res 2003;22:451-6.
16McGory ML, Zingmond DS, Nanayakkara D, Maggard MA, Ko CY. Negative appendectomy rate: Influence of CT scans. Am Surg 2005;71:803-8.
17Stella DL, Schelleman TG. Segmental infarction of the omentum secondary to torsion: Ultrasound and computed tomography diagnosis. Australas Radiol 2000;44:212-5.
18Puylaert JB. Right-sided segmental infarction of the omentum: Clinical, US and CT findings. Radiology 1992;185:169-72.
19Sanchez J, Rosado R, Ramirez D, Medina P, Mezquita S, Gallardo A. Torsion of the great omentum, treatment by laparoscopy. Surg Laparosc Endosc Percutan Tech 2002;12:443-5.