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Omental torsion, a rare cause of acute surgical abdomen
Journal of Visceral Surgery (2013) 150, 421—422
Available online at www.sciencedirect.com
SURGICAL IMAGES
Omental torsion, a rare cause of acute surgical abdomen F. Le Roux , F. Gennuso , A. Lipsker , F. Mauvais ∗ Service de chirurgie digestive, centre hospitalier de Beauvais, avenue Léon-Blum, BP 40319, 60021 Beauvais, France
KEYWORDS Torsion of the greater omentum; Acute abdominal pain; Laparoscopy
Summary Torsion of the greater omentum is a rare cause of acute abdominal pain. The symptoms of this pathology are non-specific and abdominal CT is usually necessary to make the diagnosis. Treatment is surgical and can often be performed laparoscopically. © 2013 Published by Elsevier Masson SAS.
This 55 year-old female with no previous surgical history presented with abdominal pain in the right lower quadrant and localized guarding. Laboratory findings included an elevated WBC of 11,000/L and a CRP of 9.7 mg/dL. Abdomino-pelvic CT scan with IV contrast showed a fatty anomaly in the right lower quadrant with a central ‘‘whirl sign’’ suggestive of torsion of the greater omentum. Torsion of the greater omentum is a rare cause of acute abdominal pain. This may occur primarily due to anatomic abnormalities of the omentum (bifid omentum, accessory omentum) or secondarily due to intra-abdominal or parietal lesions (cysts, tumors, adhesions) [1]. This entity typically presents as pain in the right flank or right lower quadrant and may be suggestive of acute appendicitis, acute cholecystitis, cecal diverticulitis, or infarction of an epiploic appendage. The acute pain of epiploic appendagitis, unlike greater omental torsion, is usually self-limited and resolves spontaneously without need of surgical intervention [2,3]. Laboratory findings typically show signs of inflammation due to omental ischemia distal to the torsion. The signs are non-specific making pre-operative diagnosis difficult. Oftentimes, diagnosis is only established with the help of imaging, particularly
∗
Corresponding author. Tel.: +03 44 11 22 42; fax: +03 44 11 21 74. E-mail address: [email protected] (F. Mauvais).
1878-7886/$ — see front matter © 2013 Published by Elsevier Masson SAS. http://dx.doi.org/10.1016/j.jviscsurg.2013.09.001
422
F. Le Roux et al.
abdomino-pelvic CT [4]. CT images show rotation of the omental vasculature, the so-called ‘‘whirl sign’’ (Fig. 1) associated with inflammatory infiltration of the omental fat. Resection of the omentum distal to the torsion seems to be the most appropriate treatment, in view of the large volume of necrotic omental tissue (Fig. 2), however, in some cases medical observation without surgical intervention has been reported. A laparoscopic approach allows
Figure 3. Laparoscopic view showing discoloration distal to the zone of torsion.
Figure 1. Pre-operative abdomino-pelvic CT scan with IV contrast demonstrating a ‘‘whirl sign’’ with edematous infiltration of the greater omentum.
confirmation of the diagnosis, evaluation of the severity of omental ischemia distal to the torsion, followed by either omental resection or detorsion of the greater omental volvulus (Fig. 3).
Disclosure of interest The authors declare that they have no conflicts of interest concerning this article.
References [1] Hirano Y, Oyama K, Nozawa H, et al. Left-sided omental torsion with inguinal hernia. World J Gastroenterol 2006;12:662—4. [2] Kim J, Kim Y, Cho OK, et al. Omental torsion: CT features. Abdom Imaging 2004;29:502—4. [3] Abbes Orabi N, Lardinois C, Danse E, Remue C, Léonard D, Kartheuser A. Epiploic appendagitis. J Visc Surg 2011;148(3):e225—6. [4] Lacaze L, Attignon I, Lauzanne P, Scotté M. Torsion of the greater omentum associated with a left inguinal hernia. Diagn Interv Imaging 2012;93(5):395—7. Figure 2. Resected specimen of greater omentum demonstrating volvulus with distal segmental ischemia. White arrow: margin of resection; black arrow; zone of torsion.
Available online at www.sciencedirect.com
SURGICAL IMAGES
Omental torsion, a rare cause of acute surgical abdomen F. Le Roux , F. Gennuso , A. Lipsker , F. Mauvais ∗ Service de chirurgie digestive, centre hospitalier de Beauvais, avenue Léon-Blum, BP 40319, 60021 Beauvais, France
KEYWORDS Torsion of the greater omentum; Acute abdominal pain; Laparoscopy
Summary Torsion of the greater omentum is a rare cause of acute abdominal pain. The symptoms of this pathology are non-specific and abdominal CT is usually necessary to make the diagnosis. Treatment is surgical and can often be performed laparoscopically. © 2013 Published by Elsevier Masson SAS.
This 55 year-old female with no previous surgical history presented with abdominal pain in the right lower quadrant and localized guarding. Laboratory findings included an elevated WBC of 11,000/L and a CRP of 9.7 mg/dL. Abdomino-pelvic CT scan with IV contrast showed a fatty anomaly in the right lower quadrant with a central ‘‘whirl sign’’ suggestive of torsion of the greater omentum. Torsion of the greater omentum is a rare cause of acute abdominal pain. This may occur primarily due to anatomic abnormalities of the omentum (bifid omentum, accessory omentum) or secondarily due to intra-abdominal or parietal lesions (cysts, tumors, adhesions) [1]. This entity typically presents as pain in the right flank or right lower quadrant and may be suggestive of acute appendicitis, acute cholecystitis, cecal diverticulitis, or infarction of an epiploic appendage. The acute pain of epiploic appendagitis, unlike greater omental torsion, is usually self-limited and resolves spontaneously without need of surgical intervention [2,3]. Laboratory findings typically show signs of inflammation due to omental ischemia distal to the torsion. The signs are non-specific making pre-operative diagnosis difficult. Oftentimes, diagnosis is only established with the help of imaging, particularly
∗
Corresponding author. Tel.: +03 44 11 22 42; fax: +03 44 11 21 74. E-mail address: [email protected] (F. Mauvais).
1878-7886/$ — see front matter © 2013 Published by Elsevier Masson SAS. http://dx.doi.org/10.1016/j.jviscsurg.2013.09.001
422
F. Le Roux et al.
abdomino-pelvic CT [4]. CT images show rotation of the omental vasculature, the so-called ‘‘whirl sign’’ (Fig. 1) associated with inflammatory infiltration of the omental fat. Resection of the omentum distal to the torsion seems to be the most appropriate treatment, in view of the large volume of necrotic omental tissue (Fig. 2), however, in some cases medical observation without surgical intervention has been reported. A laparoscopic approach allows
Figure 3. Laparoscopic view showing discoloration distal to the zone of torsion.
Figure 1. Pre-operative abdomino-pelvic CT scan with IV contrast demonstrating a ‘‘whirl sign’’ with edematous infiltration of the greater omentum.
confirmation of the diagnosis, evaluation of the severity of omental ischemia distal to the torsion, followed by either omental resection or detorsion of the greater omental volvulus (Fig. 3).
Disclosure of interest The authors declare that they have no conflicts of interest concerning this article.
References [1] Hirano Y, Oyama K, Nozawa H, et al. Left-sided omental torsion with inguinal hernia. World J Gastroenterol 2006;12:662—4. [2] Kim J, Kim Y, Cho OK, et al. Omental torsion: CT features. Abdom Imaging 2004;29:502—4. [3] Abbes Orabi N, Lardinois C, Danse E, Remue C, Léonard D, Kartheuser A. Epiploic appendagitis. J Visc Surg 2011;148(3):e225—6. [4] Lacaze L, Attignon I, Lauzanne P, Scotté M. Torsion of the greater omentum associated with a left inguinal hernia. Diagn Interv Imaging 2012;93(5):395—7. Figure 2. Resected specimen of greater omentum demonstrating volvulus with distal segmental ischemia. White arrow: margin of resection; black arrow; zone of torsion.