Omental infarction-an unrecognized cause of acute abdomen
http://www.100md.com
《美国医学杂志》
Department of Pediatric Surgery, Sir Ganga Ram Hospital, New Delhi, India
A 6-year-old boy was admitted to hospital complaining of periumbilical pain of 2 days duration. Pain increased with breathing or coughing and was associated with low grade fever. There was no history of vomiting. The past medical history was unremarkable. The patient weighed 23 kilograms and his oral temperature was 37.2 oC. The right side of abdomen was tender especially in right lumbar and right iliac region. Laboratory studies revealed leukocyte count of 11,000/cu.mm, predominantly polymorphs (78%). Other routine investigations were normal. The child was initially treated with intravenous fluids and parenteral antibiotics. Abdominal ultrasound showed little free fluid in the right iliac region, and distended bowel loops . The appendix was not visualized. With a presumptive diagnosis of appendicitis. the child underwent a diagnostic laparoscopy . The bowel loops were adhered to the anterior abdominal wall. On separation, omental infarct of size 3 x 4 x 6 cms was seen. There were no gangrenous changes seen. This was left alone and appendectomy was done. Post operative period was uneventful and the patient was discharged on D-3 of surgery. Histology of the appendix showed a normal vermiform appendix.
Omental infarction is a rarely considered diagnosis for acute abdomen in children. Because of its low incidence and lack of awareness among clinicians, a pre-operative diagnosis of omental infarction is rarely made. The etiology and pathogenesis of this disorder is not known. However, abnormal coagulation profile, autoimmune disorder, trauma, obesity, congenital vascular anomalies with low perfusion and extension from another inflammatory focus have been suggested.[1] In such patients, a mass is usually located in the right upper quadrant of the abdomen.[2] Males are affected twice as often as females. Symptoms may consist of sudden onset of acute abdominal pain, low grade fever and occasional vomiting. Right side omentum is more often affected than the left side.[3] Surgical resection usually results in immediate resolution of symptoms with little or no morbidity.[4] The standard McBurney incision used for suspected acute appendicitis may be inadequate for the diagnosis and resection of certain omental infarctions, which may be adherant to the ascending colon or anterior abdominal wall.[5],[6] Laparoscopic exploration circumvents this difficulty. Successful attempts at non-operative management have been made,[3],[7] albeit at a risk of leaving necrotic tissue within the peritoneal cavity. Conservative management leaves the patient with persistent pain requiring prolonged analgesics[3] or abscess formation.[5]
Omental infarction often mimics acute appendicitis pre-operatively.[4] CT scan is usually diagnostic. It delineates the infarcted omentum as a well defined area of high attenuated fat containing hyperattenuating streaks immediately deep to the parietal peritoneum with secondary thickening and inflammation of the overlying anterior abdominal wall.[8]
References
1.Varjavandi V, Lessin M, Kooros K et al. Omental infarction: Risk factors in children. J Pediatr Surg 2003; 38 : 233-235.
2.Sompayrac SW, Mindelzun RE, Silverman MP, Sze R. The greater omentum. Am J Roentgenology 1997; 168: 683-687.
3.Puylaert JB. Right side segmental infarction of the omentum: Clinical, US and CT findings. Radiology 1992; 85 : 169-172.
4.May Han Loh, Jacobsen AS, Chan Hon Chui et al. Omental infarction: A mimicker of acute appendicitis in children. J Pediatr Surg 2005; 40 : 1224-1226.
5.Helmrath MA. Right lower quadrant pain in children caused by omental infarction. Am J Surg 2001; 182 : 729-732.
6.Tolenar PL, Bast TJ. Idiopathic segmental infarction of the omentum. Br J Surg 1987; 74 : 1182.
7.Nagar H, Kessler A, Ben- Sira L et al. Omental infarction : An usual cause of acute abdomen in childhood. Pediatr Surg Int 2003; 19 : 677-679.
8.Stella DL, Schelleman TG. Segmental infarction of the omentum secondary to torsion: Ultrasound and computed tomography diagnosis. Australasian Radiology 2000;44 : 212-215. [PUBMED] [FULLTEXT](Zargar Noor Ullah, Kundal Anjani Kumar, )
A 6-year-old boy was admitted to hospital complaining of periumbilical pain of 2 days duration. Pain increased with breathing or coughing and was associated with low grade fever. There was no history of vomiting. The past medical history was unremarkable. The patient weighed 23 kilograms and his oral temperature was 37.2 oC. The right side of abdomen was tender especially in right lumbar and right iliac region. Laboratory studies revealed leukocyte count of 11,000/cu.mm, predominantly polymorphs (78%). Other routine investigations were normal. The child was initially treated with intravenous fluids and parenteral antibiotics. Abdominal ultrasound showed little free fluid in the right iliac region, and distended bowel loops . The appendix was not visualized. With a presumptive diagnosis of appendicitis. the child underwent a diagnostic laparoscopy . The bowel loops were adhered to the anterior abdominal wall. On separation, omental infarct of size 3 x 4 x 6 cms was seen. There were no gangrenous changes seen. This was left alone and appendectomy was done. Post operative period was uneventful and the patient was discharged on D-3 of surgery. Histology of the appendix showed a normal vermiform appendix.
Omental infarction is a rarely considered diagnosis for acute abdomen in children. Because of its low incidence and lack of awareness among clinicians, a pre-operative diagnosis of omental infarction is rarely made. The etiology and pathogenesis of this disorder is not known. However, abnormal coagulation profile, autoimmune disorder, trauma, obesity, congenital vascular anomalies with low perfusion and extension from another inflammatory focus have been suggested.[1] In such patients, a mass is usually located in the right upper quadrant of the abdomen.[2] Males are affected twice as often as females. Symptoms may consist of sudden onset of acute abdominal pain, low grade fever and occasional vomiting. Right side omentum is more often affected than the left side.[3] Surgical resection usually results in immediate resolution of symptoms with little or no morbidity.[4] The standard McBurney incision used for suspected acute appendicitis may be inadequate for the diagnosis and resection of certain omental infarctions, which may be adherant to the ascending colon or anterior abdominal wall.[5],[6] Laparoscopic exploration circumvents this difficulty. Successful attempts at non-operative management have been made,[3],[7] albeit at a risk of leaving necrotic tissue within the peritoneal cavity. Conservative management leaves the patient with persistent pain requiring prolonged analgesics[3] or abscess formation.[5]
Omental infarction often mimics acute appendicitis pre-operatively.[4] CT scan is usually diagnostic. It delineates the infarcted omentum as a well defined area of high attenuated fat containing hyperattenuating streaks immediately deep to the parietal peritoneum with secondary thickening and inflammation of the overlying anterior abdominal wall.[8]
References
1.Varjavandi V, Lessin M, Kooros K et al. Omental infarction: Risk factors in children. J Pediatr Surg 2003; 38 : 233-235.
2.Sompayrac SW, Mindelzun RE, Silverman MP, Sze R. The greater omentum. Am J Roentgenology 1997; 168: 683-687.
3.Puylaert JB. Right side segmental infarction of the omentum: Clinical, US and CT findings. Radiology 1992; 85 : 169-172.
4.May Han Loh, Jacobsen AS, Chan Hon Chui et al. Omental infarction: A mimicker of acute appendicitis in children. J Pediatr Surg 2005; 40 : 1224-1226.
5.Helmrath MA. Right lower quadrant pain in children caused by omental infarction. Am J Surg 2001; 182 : 729-732.
6.Tolenar PL, Bast TJ. Idiopathic segmental infarction of the omentum. Br J Surg 1987; 74 : 1182.
7.Nagar H, Kessler A, Ben- Sira L et al. Omental infarction : An usual cause of acute abdomen in childhood. Pediatr Surg Int 2003; 19 : 677-679.
8.Stella DL, Schelleman TG. Segmental infarction of the omentum secondary to torsion: Ultrasound and computed tomography diagnosis. Australasian Radiology 2000;44 : 212-215. [PUBMED] [FULLTEXT](Zargar Noor Ullah, Kundal Anjani Kumar, )