Omental infarction during acute appendicitis

Rodríguez Moncada, Rafael; López Díaz, José Ángel; Carrillo Acosta, Alberto

doi:10.1016/j.medcle.2017.11.056

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It can be primary (idiopathic) or secondary. In the first case, the etiopathogenesis is little known. An anomaly of the omentum has been suggested, with greater susceptibility to torsion and infarction.<a class="elsevierStyleCrossRef" href="#bib0030">1</a> In secondary cases, underlying causes are usually identified: cysts, tumours, adhesions, hernias (most common), etc. It usually presents with pain in the right iliac fossa. Ultrasound is usually not definitive for diagnosis, with computed tomography (CT) being the technique of choice.<a class="elsevierStyleCrossRef" href="#bib0035">2</a> The absence of inner ring and a size greater than 3cm differentiates it from epiploic appendicitis, also of benign course. Regarding treatment, there are no significant differences between surgery and conservative management (rest and anti-inflammatory agents). Some authors advocate patient monitoring in the first 24–48h, not considering surgery until clinical deterioration or the occurrence of complications (omental abscesses, intestinal obstruction, etc.).<a class="elsevierStyleCrossRef" href="#bib0040">3</a> This approach is possible when the diagnosis is confirmed by ultrasound and/or CT, and the patient is hemodynamically stable, although it has been associated with the development of omental abscesses. The surgical approach allows a complete abdominal examination and a necrosectomy of the omentum involved, providing definitive treatment and reducing the risk of abscess formation.A 22-year-old man who went to the emergency room for pain in the right iliac fossa and vomiting. Afebrile and normal vital signs. Pain in the abdomen on palpation over the right iliac fossa, with voluntary defence and positive Blumberg. Laboratory tests showed 6930leukocytes/mm3 with 67% neutrophils and a CRP of 35mg/l; rest of parameters were within normal limits. An abdominal ultrasound showed the presence of free intraperitoneal fluid and a localized omentum thickening of 5cm transverse diameter and 15mm maximum thickness, compatible with an omental infarction, without signs of appendicitis. Subsequently, an abdominal CT was performed, showing a thickening of the omentum suggesting omental infarction in the antimesenteric border of the ascending colon, confirming the ultrasonographic finding. In addition, a tubular structure of 9mm in diameter was visualized in the subhepatic region and in retrocaecal position with a calcium image inside (possible appendicolith), as well as adjacent free fluid and 2 reactive lymphadenopathies. A concomitant acute appendicitis could not be ruled out. Given these findings, and not being able to rule out an appendicitis, a conservative approach was not feasible, so urgent laparoscopic surgery was chosen, performing appendectomy and segmental omental resection of the distal omental infarction. The histopathological report revealed the presence of congestive omental tissue with significant bleeding and multifocal fat necrosis with reactive mesothelial hyperplasia, confirming the diagnosis of omental infarction. The appendix showed signs of acute phlegmonous appendicitis. The postoperative period was uneventful, and the patient was discharged.After performing a literature review, to our knowledge, this is the third case described in the literature that reports this unusual association. In the first case, described in an adult woman, the diagnosis of appendicitis was established, observing an omental infarction during the inspection of the omentum in surgery. Subsequently, both findings were confirmed histologically.<a class="elsevierStyleCrossRef" href="#bib0045">4</a> In the second case, described in a 7-year-old male, abdominal ultrasound showed omental infarction and indirect signs of concomitant acute appendicitis.<a class="elsevierStyleCrossRef" href="#bib0050">5</a> In this case, abdominal ultrasound suggested the presence of an omental infarct that led to an abdominal CT scan that was used to diagnose a possible associated appendicitis in a patient without fever or leucocytosis, confirming both entities in the histological examination. It is common for omental infarction to be erroneously classified as appendicitis, confirming a normal appendix during surgery or after its histological analysis. However, although it is uncommon, both entities can coexist, so in the case of omental infarction, the appendix should be checked, since the presence of an associated appendicitis modifies the management of the condition. Likewise, omental infarction must be considered in any patient with pain in the right hemiabdomen." "pdfFichero" => "main.pdf" "tienePdf" => true "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "Please cite this article as: Rodríguez Moncada R, López Díaz JÁ, Carrillo Acosta A. Infarto omental en el transcurso de una apendicitis aguda. Med Clin (Barc). 2018;151:e39–e40." ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0015" "bibliografiaReferencia" => array:5 [ 0 => array:3 [ "identificador" => "bib0030" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Infarto omental primario como causa de abdomen agudo no quirúrgico: diagnóstico por imagen" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:1 [ 0 => "C.L. 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Al Ansari" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1155/2013/193546" "Revista" => array:5 [ "tituloSerie" => "Case Rep Surg" "fecha" => "2013" "volumen" => "2013" "paginaInicial" => "193546" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/24062963" "web" => "Medline" ] ] ] ] ] ] ] ] 2 => array:3 [ "identificador" => "bib0040" "etiqueta" => "3" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Modern management of omental torsion and omental infarction: a surgeon's perspective" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:4 [ 0 => "E. Itenberg" 1 => "J. Mariadason" 2 => "J. Khersonsky" 3 => "M. Wallack" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1016/j.jsurg.2010.01.003" "Revista" => array:6 [ "tituloSerie" => "J Surg Educ" "fecha" => "2010" "volumen" => "67" "paginaInicial" => "44" "paginaFinal" => "47" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/20421090" "web" => "Medline" ] ] ] ] ] ] ] ] 3 => array:3 [ "identificador" => "bib0045" "etiqueta" => "4" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Simultaneous idiopathic segmental infarction of the great omentum and acute appendicitis: a rare association" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "L. Battaglia" 1 => "F. Belli" 2 => "A. Vannelli" 3 => "G. Bonfanti" 4 => "G. Gallino" 5 => "E. Poiasina" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1186/1749-7922-3-30" "Revista" => array:5 [ "tituloSerie" => "World J Emerg Surg" "fecha" => "2008" "volumen" => "3" "paginaInicial" => "30" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/18959804" "web" => "Medline" ] ] ] ] ] ] ] ] 4 => array:3 [ "identificador" => "bib0050" "etiqueta" => "5" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Simultaneous omental infarction and acute appendicitis in a child" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:2 [ 0 => "H.T. Koay" 1 => "H.E. Mahmoud" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:6 [ "tituloSerie" => "Med J Malaysia" "fecha" => "2015" "volumen" => "70" "paginaInicial" => "42" "paginaFinal" => "44" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/26032530" "web" => "Medline" ] ] ] ] ] ] ] ] ] ] ] ] ] "idiomaDefecto" => "en" "url" => "/23870206/0000015100000007/v1_201810260641/S2387020618303243/v1_201810260641/en/main.assets" "Apartado" => array:4 [ "identificador" => "43309" "tipo" => "SECCION" "en" => array:2 [ "titulo" => "Letters to the Editor" "idiomaDefecto" => true ] "idiomaDefecto" => "en" ] "PDF" => "https://static.elsevier.es/multimedia/23870206/0000015100000007/v1_201810260641/S2387020618303243/v1_201810260641/en/main.pdf?idApp=UINPBA00004N&text.app=https://www.elsevier.es/" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2387020618303243?idApp=UINPBA00004N"]

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Vol. 151. Issue 7.

Pages e39-e40 (October 2018)

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