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Primary idiopathic segmental infarction of the greater omentum
Volume 77 Number 3
Primary idiopathic segmental infarction of the greater omentum P a u l A. W e n g e r t , Jr,. M . D . , a n d R e z a G. Azizkhan, M . D . , F.R.C.S., F.A.C.S. ttAR.RIS B URG~ PA.
AMONG T~E u n c o m m o n causes of a c u t e a b d o m i n a l p a i n is idiopathic infarction of the greater o m e n t u m . F e w e r t h a n 100 cases h a v e been r e p o r t e d to date, a n d the disease is not even m e n t i o n e d in stand a r d p e d i a t r i c texts. 1-a O f the 3 cases seen in this large c o m m u n i t y hospital over the past 10 years, 2 o c c u r r e d in adults. This is a rep o r t of the findings in a child who recently presented w i t h this rarely described entity. CASE REPORT
A 10-year-old boy developed acute right lower quadrant pains while playing on the eve prior to admission to the hospital. The pains persisted and were aggravated by any kind of activity. There was no nausea, vomiting, or diarrhea. Physical examination at the time of admission showed a temperature of 100 ~ F., a pulse rate of 80 per minute, respirations of 20 per minute, and a blood pressure of 130/60. The abdomen was firm; there were depressed bowel sounds and marked rebound tenderness in the right lower quadrant. A rectal examination revealed no masses or significant tenderness. Laboratory data included hemoglobin 12.8 Gin. per cent, hematocrit 40 per cent, white blood cells 11,700 per cubic millimeter with 80 per cent segmented neutrophils and 9 per cent stab forms. Urinalysis was normal. A diagnosis of acute appendicitis was made and the patient was transferred to the operating room for surgery.
From the Department of Surgery, Harrisburg Polyclinic Hospital.
Brie[ clinical and laboratory observations
459
A classical McBurney's incision was made. Just prior to opening the peritoneum, dark necrotic-appearing tissue was noted in the right paracolonic gutter. On opening the peritoneum, the mass proved to be a blackened necrotic segment of the inferior lateral aspect of the greater omentum, measuring 10 x 3 x 4 cm. The mass was impacted deep in the lateral gutter but was readily freed by blunt dissection. A moderate amount of hemorrhagic serous fluid was present in the abdomen. The cecum, colon, and ascending colon showed secondary inflammation with edematous thickening. Close examination revealed no other primary abdominal pathology. The devitalized segment of omentum was widely resected and an incidental appendectomy was performed. Pathologic examination of the specimen showed interstitial hemorrhage and intravascular thrombosis with segmental infarction of the omentum. The postoperative course was routine, and the child was discharged on the sixth postoperative day in satisfactory condition. He has remained free of further symPtoms. DISCUSSION T h e most c o m m o n symptom in a p a t i e n t of any age w i t h p r i m a r y i d i o p a t h i c infarction of the g r e a t e r o m e n t u m is right lower q u a d r a n t pain, which leads to a p r e s u m p tive diagnosis of acute appendicitis. I n adults the second most c o m m o n site of p a i n is right u p p e r q u a d r a n t , a n d a tentative diagnosis of acute cholecystitis is often made. ~ I n all children reported, however, the p r e o p e r a t i v e symptoms have led to a diagnosis of a c u t e appendicitis. T h e disease was once t h o u g h t to be rare a m o n g children, b u t a b o u t 14 p e r cent of all patients have been in a p e d i a t r i c age range, s Characteristically, one finds at the time of surgery, a wedge of necrotic o m e n t u m of variable size a n d a m o d e r a t e a m o u n t of serosanguineous transudate. T h e classification of o m e n t a l infarctions, as p r o p o s e d by T a k i t a , 1~ includes a closely allied s y n d r o m e - - p r i m a r y o m e n t a l torsion with subsequent infarction. This syndrome also has a predilection to the right lower q u a d r a n t area, again resulting in a p r e o p erative diagnosis of acute a p p e n d i c i t i s 2
460
Brie[ clinical and laboratory observations
Both conditions are predicated on vascular compromise and resulting necrosis. 5 Wrzesinski 11 described 4 criteria for establishing the diagnosis of primary idiopathic segmental omental infarction. (1) T h e infarction must be idiopathic in that there are no other etiologic factors, including torsion, to initiate the process. (2) The lesion must be segmental and not associated with massive vascular occlusion. (3) It must be primary in the o m e n t u m and not secondary to a disease of a neighboring structure. (4) It should have the typical gross and microscopic findings, especially excluding a twisted pedicle of omentum. T h e etiology of this condition is vague and has been variously theorized to be due to anatomic7 vascular, 9 or developmental 4 irregularities. Each hypothesis is largely unsupported. W h a t e v e r the basic defect, a real or remote episode of trauma is frequently found on careful review of the history. There is unanimous agreement on m a n a g e m e n t of this problem at the time of surgery; this includes wide resection of the infarcted o m e n t u m a n d an incidental appendectomy. No morbidity has been recorded from performing an appendectomy, and the prognosis is uniformly excellent. T h e condition has not been known to recur.
blood hemoglobin determination in Rb erytbroblastosis fetalis Calvin
J.
Hobel, M.D.
TORRANGE~ C A L I F .
From the National Women's Hospital, University o[ Auckland. Supported in part by a Bank of America Giannini Research Grant. ' Address: 1000 W. Carson St., Torrance, Call], 90509.
The Journal o[ Pediatrics September 1970
REFERENCES 1. Barnett, H. L., and Einhorn, A. H.: Pediatrics, New York, 1968, Appleton-CenturyCrofts, Inc. 2. Cooke, R. E., and Levin, S.: The biologic basis of pediatric practice, New York, 1968, McGraw~Hill Book Company, Inc. 3. Nelson, W. E., Vaughan, V. C., III, and McKay, R. J., Jr.: Textbook o~ pediatrics, ed. 9, PhiladeJphia, 1969, W. B. Saunders Company, 4. Epstein, L. I., and Lempke, R. D,: Primary idiopathic segmentaI infarction of the greater omentum. Case report and collective review of the literature, Ann. Surg. 167: 437, 1968. 5. Fahlund, G. T. R., and Smedley, W. P.: Primary torsion of greater omentum. Report of four cases, Amer. Surg. 31: 285, 1965. 6. Fahlund, G. T. R., and Smedley, W. P.: Primary omental torsion in children, Penn. Med. 67: 47, 1966. 7. Eger, S. H., and Barto, R. E., Jr.: Primary idiopathic segmental infarction of greater omentum, Amer. J. Surg. 78: 518, 1949. 8. Perry, J. F., Jr.: Primary segmental infarction of the omentum in children, Surgery 56: 584, 1964. 9 . Pines, B., and Rabinovitch, J.: Idiopathic segmental infarction of the greater omentum, Surg. Gynec. Obstet. 71. 80, 1940. 10. Takita, H.: Idiopathic segmental infarction of the greater omentum, Canad. Med. Ass. J. 93: 223, 1965. 11. Wrzesinski, J. T., Firestone, S. D., and Walske, B. R.: Primary idiopathic segmental infarction of the greater omentum, Surgery 39: 663, 1956.
B L o o D O J ~ T A I N E D from the fetal scalp during labor has been subjected to several analyses which have helped obstetricians to man.age intrauterine fetal disorders. T h e most thoroughly studied parameter has been the acid-base status of the fetus in relation to fetal distress? -~ Fetal hypogIycemia has been diagnosed by scalp blood sampling and corrected by infusions of glucose to the mother. 4 Studies on the effect of anemia on the acid-base status of the fetus with hemolytic disease have shown that during the second stage of labor, the anemic fetus becomes more acidotic than the nonanemic fetus? T h e purpose of this communication is to point out the value of scalp blood sampling in the evaluation of the degree of anemia of
Primary idiopathic segmental infarction of the greater omentum P a u l A. W e n g e r t , Jr,. M . D . , a n d R e z a G. Azizkhan, M . D . , F.R.C.S., F.A.C.S. ttAR.RIS B URG~ PA.
AMONG T~E u n c o m m o n causes of a c u t e a b d o m i n a l p a i n is idiopathic infarction of the greater o m e n t u m . F e w e r t h a n 100 cases h a v e been r e p o r t e d to date, a n d the disease is not even m e n t i o n e d in stand a r d p e d i a t r i c texts. 1-a O f the 3 cases seen in this large c o m m u n i t y hospital over the past 10 years, 2 o c c u r r e d in adults. This is a rep o r t of the findings in a child who recently presented w i t h this rarely described entity. CASE REPORT
A 10-year-old boy developed acute right lower quadrant pains while playing on the eve prior to admission to the hospital. The pains persisted and were aggravated by any kind of activity. There was no nausea, vomiting, or diarrhea. Physical examination at the time of admission showed a temperature of 100 ~ F., a pulse rate of 80 per minute, respirations of 20 per minute, and a blood pressure of 130/60. The abdomen was firm; there were depressed bowel sounds and marked rebound tenderness in the right lower quadrant. A rectal examination revealed no masses or significant tenderness. Laboratory data included hemoglobin 12.8 Gin. per cent, hematocrit 40 per cent, white blood cells 11,700 per cubic millimeter with 80 per cent segmented neutrophils and 9 per cent stab forms. Urinalysis was normal. A diagnosis of acute appendicitis was made and the patient was transferred to the operating room for surgery.
From the Department of Surgery, Harrisburg Polyclinic Hospital.
Brie[ clinical and laboratory observations
459
A classical McBurney's incision was made. Just prior to opening the peritoneum, dark necrotic-appearing tissue was noted in the right paracolonic gutter. On opening the peritoneum, the mass proved to be a blackened necrotic segment of the inferior lateral aspect of the greater omentum, measuring 10 x 3 x 4 cm. The mass was impacted deep in the lateral gutter but was readily freed by blunt dissection. A moderate amount of hemorrhagic serous fluid was present in the abdomen. The cecum, colon, and ascending colon showed secondary inflammation with edematous thickening. Close examination revealed no other primary abdominal pathology. The devitalized segment of omentum was widely resected and an incidental appendectomy was performed. Pathologic examination of the specimen showed interstitial hemorrhage and intravascular thrombosis with segmental infarction of the omentum. The postoperative course was routine, and the child was discharged on the sixth postoperative day in satisfactory condition. He has remained free of further symPtoms. DISCUSSION T h e most c o m m o n symptom in a p a t i e n t of any age w i t h p r i m a r y i d i o p a t h i c infarction of the g r e a t e r o m e n t u m is right lower q u a d r a n t pain, which leads to a p r e s u m p tive diagnosis of acute appendicitis. I n adults the second most c o m m o n site of p a i n is right u p p e r q u a d r a n t , a n d a tentative diagnosis of acute cholecystitis is often made. ~ I n all children reported, however, the p r e o p e r a t i v e symptoms have led to a diagnosis of a c u t e appendicitis. T h e disease was once t h o u g h t to be rare a m o n g children, b u t a b o u t 14 p e r cent of all patients have been in a p e d i a t r i c age range, s Characteristically, one finds at the time of surgery, a wedge of necrotic o m e n t u m of variable size a n d a m o d e r a t e a m o u n t of serosanguineous transudate. T h e classification of o m e n t a l infarctions, as p r o p o s e d by T a k i t a , 1~ includes a closely allied s y n d r o m e - - p r i m a r y o m e n t a l torsion with subsequent infarction. This syndrome also has a predilection to the right lower q u a d r a n t area, again resulting in a p r e o p erative diagnosis of acute a p p e n d i c i t i s 2
460
Brie[ clinical and laboratory observations
Both conditions are predicated on vascular compromise and resulting necrosis. 5 Wrzesinski 11 described 4 criteria for establishing the diagnosis of primary idiopathic segmental omental infarction. (1) T h e infarction must be idiopathic in that there are no other etiologic factors, including torsion, to initiate the process. (2) The lesion must be segmental and not associated with massive vascular occlusion. (3) It must be primary in the o m e n t u m and not secondary to a disease of a neighboring structure. (4) It should have the typical gross and microscopic findings, especially excluding a twisted pedicle of omentum. T h e etiology of this condition is vague and has been variously theorized to be due to anatomic7 vascular, 9 or developmental 4 irregularities. Each hypothesis is largely unsupported. W h a t e v e r the basic defect, a real or remote episode of trauma is frequently found on careful review of the history. There is unanimous agreement on m a n a g e m e n t of this problem at the time of surgery; this includes wide resection of the infarcted o m e n t u m a n d an incidental appendectomy. No morbidity has been recorded from performing an appendectomy, and the prognosis is uniformly excellent. T h e condition has not been known to recur.
blood hemoglobin determination in Rb erytbroblastosis fetalis Calvin
J.
Hobel, M.D.
TORRANGE~ C A L I F .
From the National Women's Hospital, University o[ Auckland. Supported in part by a Bank of America Giannini Research Grant. ' Address: 1000 W. Carson St., Torrance, Call], 90509.
The Journal o[ Pediatrics September 1970
REFERENCES 1. Barnett, H. L., and Einhorn, A. H.: Pediatrics, New York, 1968, Appleton-CenturyCrofts, Inc. 2. Cooke, R. E., and Levin, S.: The biologic basis of pediatric practice, New York, 1968, McGraw~Hill Book Company, Inc. 3. Nelson, W. E., Vaughan, V. C., III, and McKay, R. J., Jr.: Textbook o~ pediatrics, ed. 9, PhiladeJphia, 1969, W. B. Saunders Company, 4. Epstein, L. I., and Lempke, R. D,: Primary idiopathic segmentaI infarction of the greater omentum. Case report and collective review of the literature, Ann. Surg. 167: 437, 1968. 5. Fahlund, G. T. R., and Smedley, W. P.: Primary torsion of greater omentum. Report of four cases, Amer. Surg. 31: 285, 1965. 6. Fahlund, G. T. R., and Smedley, W. P.: Primary omental torsion in children, Penn. Med. 67: 47, 1966. 7. Eger, S. H., and Barto, R. E., Jr.: Primary idiopathic segmental infarction of greater omentum, Amer. J. Surg. 78: 518, 1949. 8. Perry, J. F., Jr.: Primary segmental infarction of the omentum in children, Surgery 56: 584, 1964. 9 . Pines, B., and Rabinovitch, J.: Idiopathic segmental infarction of the greater omentum, Surg. Gynec. Obstet. 71. 80, 1940. 10. Takita, H.: Idiopathic segmental infarction of the greater omentum, Canad. Med. Ass. J. 93: 223, 1965. 11. Wrzesinski, J. T., Firestone, S. D., and Walske, B. R.: Primary idiopathic segmental infarction of the greater omentum, Surgery 39: 663, 1956.
B L o o D O J ~ T A I N E D from the fetal scalp during labor has been subjected to several analyses which have helped obstetricians to man.age intrauterine fetal disorders. T h e most thoroughly studied parameter has been the acid-base status of the fetus in relation to fetal distress? -~ Fetal hypogIycemia has been diagnosed by scalp blood sampling and corrected by infusions of glucose to the mother. 4 Studies on the effect of anemia on the acid-base status of the fetus with hemolytic disease have shown that during the second stage of labor, the anemic fetus becomes more acidotic than the nonanemic fetus? T h e purpose of this communication is to point out the value of scalp blood sampling in the evaluation of the degree of anemia of