OMENTAL INFARCTION

Introduction Omental infarction, sometimes idiopathic but more commonly associated with omental torsion, is a rare cause of acute abdomen in adults and children. Approximately 0.1% of children undergo laparotomy for suspected appendicitis that is diagnosed later surgically as omental infarction associated with torsion. Omental infarction is a rare cause of acute abdominal pain in children; more than 85% of reported cases occur in adults. 15% of primary omental torsions are found in children, the ratio girls/boys being 1.2.

Definitions Omental infarction is a rare cause of acute abdomen. It typically simulates acute appendicitis, with clinical features that include abdominal pain of a few days duration, most often localized in the right lower or upper quadrant. The manifestation of right-sided pain may lead to clinical misdiagnosis of omental infarction as appendicitis or cholecystitis

Anatomy The greater omentum is composed of a double layer of peritoneum that hangs down like an apron from the greater curvature of the stomach and the proximal part of the duodenum, covering the small bowel. Its descending and ascending portions fuse to form a four-layer vascular fatty apron (the gastrocolic ligament), with a space contiguous with the lesser sac. The greater omentum has considerable mobility and moves around the peritoneal cavity. It functions as a visceral fixation and serves to shield an abnormality and limit its spread. However, it is also a common location for neoplastic intraperitoneal seeding and infectious processes because it is bathed in the peritoneal fluid. The greater omentum is composed mainly of fatty tissue, with some thin serpentine gastroepiploic vessels. The lesser omentum, which is a combination of the gastrohepatic and hepatoduodenal ligaments, connects the lesser curvature of the stomach and proximal duodenum with the liver and covers the lesser sac anteriorly. The gastrohepatic ligament contains the left gastric vessels and left gastric lymph nodes. The hepatoduodenal ligament, the thickened edge of the lesser omentum, contains the portal vein, hepatic artery, extrahepatic bile duct, and hepatic nodal group.

Classification Traditionally, omental infarction has been labeled as being with or without torsion. Torsion of the omentum is the main reason for infarction and two different forms have been described: primary torsions (without other pathologic intraabdominal findings) and secondary torsions (tumors, cysts, inflammatory changes, adhesions, hernias). This classification is clinically irrelevant because treatment is identical in all cases.

Table 1: Classification of omental infarction

Torsion-related

Nontorsion-related (thrombosis)

Primary (idiopathic)

Spontaneous infarction

Secondary to adhesions, hernias, or tumours

Hypercoagulable states

Vascular abnormality

Trauma

Etiology The cause is unknown, but a particular risk factor concerns obesity. The theories about the causes of omental infarction include anomalous arterial supply to the omentum, kinking of the veins associated with increased intra-abdominal pressure, or vascular congestion after large meals. Predisposing factors of primary omental torsion have been reported: bifid omentum, tongue like portion of omentum and last but not least obesity. Secondary torsion may be caused by attachment of part of the omentum to acquired lesions (hernias, cysts, tumors, previous

surgical scars) or may be associated with a primary congenital defect in the attachment of the omental portion of the cecum, ascending colon or both.

Histopathology Histopathological findings of the resected omental specimen confirmed fresh hemorrhagic infiltrations of the tissue, partial thrombosis of the small vessels and, in some parts, necrotic fatty tissues with an acute inflammatory cellular infiltrate.

Symptoms Children with omental infarction typically present with sudden onset of right-sided abdominal pain and tenderness. In most patients the tenderness is localized. Most kids also tend to be afebrile and do not have any gastrointestinal symptoms such as nausea or vomiting.

Diagnosis Preoperative diagnosis is difficult, as right omental involvement is much more common and clinical signs and symptoms are usually nonspecific; they may thus mimic acute appendicitis or cholecystitis. The diagnosis may be confirmed by abdominal ultrasound. In cases of doubt, a computed tomography scan of the abdomen can help in the differential diagnosis. However, diagnosis of an omental infarction has traditionally been made intraoperatively during an exploratory laparotomy or laparoscopy.

Treatment Although some surgeons advocate conservative treatment, many believe that laparoscopic excision is the treatment of choice. After the infarcted omentum is removed, the child's clinical symptoms resolve rapidly, and the possibility of abscess formation or other complications, such as bowel obstruction caused by adhesions, is minimized.. However, segmental omental infarction may be a self-limited, benign condition, resolving spontaneously. If treated conservatedly, there is an increased risk of complications which include adhesions with bowel obstruction and abscess formation. In contrast, postoperative complications are rare and symptoms quickly resolve after surgery.

Prognosis In most patients segmental omental infarction is a self-limiting, benign condition that may resolve spontaneously. Prognosis is excellent like in the adults and the problem of complications is academic. The inflammatory response resolves with retraction and fibrosis leading to either complete healing or auto-amputation. Reported complications include adhesions with bowel obstruction and abscess formation.