|LETTER TO EDITOR
|Year : 2014 | Volume
| Issue : 3 | Page : 239-240
Primary omental torsion in a pregnant woman
Pratik R Shah, Ajay M Rajyaguru, Jatin G Bhatt
Department of Surgery, P.D.U. Government Medical College, Rajkot, Gujarat, India
|Date of Web Publication||27-May-2015|
Pratik R Shah
G/6, Swayambhu Appartment, Near Azad Society, Ambavadi, Ahmedabad - 380 015, Gujarat
Source of Support: None, Conflict of Interest: None
|How to cite this article:|
Shah PR, Rajyaguru AM, Bhatt JG. Primary omental torsion in a pregnant woman. Astrocyte 2014;1:239-40
Omental torsion is a rare cause of acute abdomen. When the greater omentum is twisted around its axis, perfusion defects, and vascular impairment of the organ are possible. As a result, different pathological modifications are possible, from simple edema to ischemia and gangrene of the omentum. Omental torsion is responsible for 0.1% of laparotomies performed for acute appendicitis in children.  This report describes one case of a male adult who presented with acute abdomen and in whom omental torsion was the definitive surgical diagnosis. Primary torsion of omentum is a rare surgical emergency and consequently is seldom diagnosed correctly.
A 30-year-old woman gravida 2, para 1 was admitted to the hospital in 19 th week of pregnancy with 1-day history of pain in right lower abdomen, which was aggravated by movement and coughing associated with nausea and bilious vomiting. There was no history of trauma, bowel or bladder disturbance of any per vaginal discharge. No history of similar complaints in the past.
On examination, she had mild pallor, vitals were temperature- 99F, pulse- 110/min, blood pressure - 130/90 mm of Hg and on per abdominal examination there was marked tenderness in right iliac fossa. Blood investigations revealed that hemoglobin- 10.5 gm%, total count-14000/cumm, differential count- 65/36/01/00, erythrocyte sedimentation rate- mm/1 st h. Ultrasonography abdomen suggested minimal fluid collection in right iliac fossa without any lump formation or appendicitis. There was normal fetal wellbeing. Hence, probable diagnosis of acute appendicitis was made.
Due to worsening of abdominal pain and persistent tachycardia even with conservative treatment, exploration was done through grid iron incision. On exploration normal appendix, terminal ileum without any diverticulum was found. However, there was serosanguinous fluid in right iliac fossa and paracolic gutter and twisted omentum with distal ischemia was found [Figure 1]. This was excised, and appendectomy was done. Histopathology revealed normal appendix and 45 g of infarcted omentum. Further postoperative course and pregnancy were uneventful, and the woman delivered a baby at term.
| Discussion|| |
Torsion of omentum is a rare entity, first described by Eitel in 1899.  Torsion of the omentum may be primary or secondary. The differential diagnosis includes acute appendicitis, acute cholecystitis, cecal diverticulitis and other diseases. ,, Primary torsion occurs in male more commonly than females with a ratio of 3:2 in 20-30 years of age. The primary cause is unknown, but Leither et al. described predisposing and precipitating factors. Predisposing factors were tongue-like projection from the edge of the omentum, bifid omentum, accessory omentum and obesity associated abnormal deposition of fat within omentum.  Paye suggested that the venous reductancy in relation to the arterial supply to omentum may be a predisposing factor.
Precipitating factors were those that cause displacement of the omentum such as heavy exercises, straining and hyperperistalsis associated with overeating. Primary torsion is always unipolar, and secondary torsion is, usually, associated with adhesions and hernias (bipolar). Right sided portion of the omentum is more commonly involved because of more weight and freedom. 
Patient, usually, present with complain of the acute onset of moderate to severe pain that localize to the right lower quadrant. Additionally patient may have nausea, vomiting, low-grade fever along with mild leukocytosis. Examination will reveal tenderness and guarding in right iliac fossa. So, the diagnosis of acute appendicitis and its complications can be made as in our case. Similarly left sided torsion may be misdiagnosed as acute diverticulitis and mismanaged conservatively. So, left sided torsion is less frequent as less operated. The involved omentum may demonstrate signs of hemorrhage, congestion and infarction. If left untreated may become a source of infection and abscess formation with secondary adhesions and scarring. ,
Abdominal ultrasound is important to exclude acute cholecystitis and shows an ovoid or cakelike hyperechoic mass adherent to the peritoneum located in the umbilical region or anterolaterally to the right half of the colon. Doppler sonography sometimes shows vessels within the mass and peripheral hyperemia. 
In the case of omental torsion, the computed tomography-scan shows an infarcted omentum as an area of high-attenuated fat containing hyperattenuated streaks just beneath the parietal peritoneum with thickening of the overlying anterior abdominal wall. Another finding can be a whirling pattern of the mesentery or fluid accumulation within the abdomen. Unfortunately, all these findings can be observed in various other conditions, such as in lipoma, liposarcoma, angiomyolipoma, teratoma, mesenteric lipodystrophy, pseudomyxoma peritonei, epiploic appendagitis, segmental infarction of the omentum and intestinal volvulus. CT scan has been used in the diagnosis of the omental torsion as it is very sensitive for the omental mass, but less specific for the diagnosis of torsion. To make the correct diagnosis, some authors recommend laparoscopy as a diagnostic and therapeutic method of choice in cases of omental torsion. ,
In our case, no predisposing factors could be identified. Acute appendicitis was the initial clinical possibility, and the diagnosis was finally established intraoperatively. Traditionally, the standard treatment for omental torsion is a resection of the involved segment of omentum. However, with the success of imaging tools there are many reported cases of omental torsion that have been successfully managed by conservative treatment, especially in patients with no associated complications. ,
| Conclusion|| |
Primary omental torsion appears with a wide variety of clinical manifestations. It can mimic various other causes of acute abdomen; surgeons should always consider it in the differential diagnosis of acute abdominal pain. In the majority of cases, the surgical removal of the diseased omentum remains the treatment of choice. Patients with uncomplicated omental torsion can be safely managed with conservative treatment.
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