World Journal of

Emergency
Surgery
Bio Med Centra l
Review
Open
Access
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i
n
farction of the great
omentum and acute
appendicitis: a rare
association
Luigi Battaglia*, Filiberto Belli, Alberto
Vannelli, Giuliano Bonfanti,
Gianfrancesco Gallino, Elia Poiasina,
Mario Rampa, Marco Vitellaro and
Ermanno Leo
Address: olo!rectal ancer "urger# $nit, %epartment of "urger#, Fonda&ione 'R"
('stituto )a&ionale dei *umori(, +ia Vene&ian, , ! Milan, -.,//, 'tal#
Email: Luigi Battaglia* ! luigi0battaglia1istitutotumori0mi0it2 Filiberto Belli !
luigi0battaglia1istitutotumori0mi0it2
Alberto Vannelli ! luigi0battaglia1istitutotumori0mi0it2 Giuliano Bonfanti !
luigi0battaglia1istitutotumori0mi0it2
Gianfrancesco Gallino ! luigi0battaglia1istitutotumori0mi0it2 Elia Poiasina !
luigi0battaglia1istitutotumori0mi0it2
Mario Rampa ! luigi0battaglia1istitutotumori0mi0it2 Marco Vitellaro !
luigi0battaglia1istitutotumori0mi0it2
Ermanno Leo ! luigi0battaglia1istitutotumori0mi0it
* orresponding aut3or
Published: 29 October 2008
Received: 31 August
2008
World Journal of Emergency Surgery 2008,
3:30
doi:10118!"1#$9%#922%
3%30
Acce&ted: 29 October
2008
'his article is available (ro): htt&:""wwww*esorg"content"3"1"30
+ 2008 ,attaglia et al- licensee ,io.ed Central /td
'his is an O&en Access article distributed under the ter)s o( the Creative Co))ons
Attribution /icense 0 htt&:""creativeco))onsorg"licenses"b1"2 0 2, which &er)its
unrestricted use, distribution, and re&roduction in an1 )ediu), &rovided the original wor3
is &ro&erl1 cited
Abstract
4dio&athic seg)ental in(arction o( the greater
o)entu) is an unco))on cause o( acute
abdo)en 'he etiolog1 is still unclear and the
s1)&to)s )i)ic acute a&&endicitis 4ts
&resentation si)ultaneousl1 with acute
a&&endicitis is still )ore in(re5uent 6e
&resent a case o( a $#%1ear old wo)an
without signi(icant &revious )edical histor1,
ad)itted with an acute abdo)en, in which the
clinical diagnosis was acute a&&endicitis and
in who) an in(arcted seg)ent o( right side o(
the greater o)entu) was also (ound at
la&aroto)1 As the etiolog1 is un3nown, we
highlighted so)e o( the &ossible theories, and
e)&hasi7e the i)&ortance o( o)ental
in(arction even in the &resence o( acute
a&&endicitis as a coincident intra&eritoneal
&athological condition
Revie
4mental 'nfarction, t3e result of
impaired perfusion to t3e greater
omentum, is a rare entit#0 First
described b# Bus3 in ,567 8,9, t3e
incidence of idiopat3ic segmental
infarction of t3e greater omentum is
estima
ted to
be
.0,:
of t3e
total
laparo
tomie
s
perfor
med
for
acute
abdo
men
8-90
E+en
t3oug
3
more
t3an
,..
cases
3a+e
been
report
ed in
t3e
literat
ure,
its
associ
ation
;it3
acute
appen
dicitis
3as
been
rarel#
docu
mente
d0
More
intere
stingl
#, t3is
case
also
presen
ted in
a
femal
e
patien
t,
;3ic3
ma<es
t3e
obser
+a!
tion
far
more
unco
mmon
0
*3e purpose of t3is report is to
describe our first e=peri!ence ;it3 t3is
condition0 E+en t3oug3 t3e etiolog# is
un<no;n, ;e 3ig3lig3t some of t3e
possible t3eories0 Anal#sis of some
collecti+e re+ie;s 8/9 and our
e=perience ;it3 t3is patient indicate
t3at t3e s#mptoms, clinical find!ings,
preoperati+e diagnosis and
management of t3is con!dition are
almost identical, e+en in c3ildren0
A >?!#ear!old ;oman presented to t3e
emergenc# depart!ment complaining
of rig3t lo;er abdominal pain of >5
3ours of duration along ;it3 3ig3
fe+er and nausea ;it3!out +omiting0
*3e patient 3ad no rele+ant pre+ious
medi!cal 3istor#0 *3e pain started at
t3e rig3t paraumbilical and
Page 1 o( 8
(page number not for citation purposes)
World
Journal of
Emergency
Surgery
2008, 3:30
subcostal
region,
radiating
do;n to t3e
rig3t iliac
fossa region0
P3#sical
e=amination
re+ealed
normal +ital
signs, no
fe+er, no
abdominal
distension
but a tender
abdomen in
t3e rig3t
lo;er
@uadrant
;it3
guarding and
rebound ten!
derness0 )o
mass ;as
palpable0
Results of
laborator#
stud!ies
re+ealed
leucoc#tocis
;it3 a AB
count of
,-B7.C mm
/
and a RP of
,?/ mgCL0
Bot3, t3e
plain =!ra#s
and t3e
ultrasonograp
3# of t3e
abdomen
s3o;ed no
abnor!
malities0 )o
furt3er tests
;ere
performed,
and t3e
patient ;as
ta<en to t3e
operating
room ;it3
t3e diagnosis
of acute
appendicitis
after
appropriate
antibiotic
prop3#la=is
;as
administrated
0
"urger# ;as
performed
t3roug3 a
rig3t
pararectal
incision in
order to
allo; a good
e=amination
of t3e of t3e
ceco!
htt&:""wwww*
esorg"conten
t"3"1"30
appendicular
and
surrounding
area0 At
surger#, t3e
omen!tum
;as found to
be grossl#
dar< and
t3ic<ened0
Ad3e!sions
bet;een t3e
greater
omentum and
t3e rig3t
abdominal
;all ;ere
seen0 Furt3er
e=ploration
re+ealed
infarction
;it3out
torsion of t3e
rig3t segment
of t3e greater
omentum
locali&ed at
t3e inferior
rig3t
@uadrant
region in an
area of
appro=imatel
# ,-. cm
-
D,. cm per
,- cmE DFig0
,E0 *3e
appendi= ;as
edematous
and
er#t3ema!
tous
macroscopica
ll#, located in
a preileal
position0 A
small amount
of
serosanguine
ous fluid ;as
seen at t3e
rig3t iliac
fossa region0
*3e infarcted
segment of
t3e omentum
;as released
from t3e
surrounding
ad3esions,
resected and
remo+ed0
Fur!t3er
inspection
s3o;ed no
ot3er
abnormalities
0 *3ere!fore,
a partial
omental
resection and
a base!apical
appendectom
# ;ere
performed0
!igure "
Macrosc
opical
appeara
nce of
the
infarcted
area of
the
greater
omentu
m found
during
laparoto
my for
acute
appendi
citis#
9ote the
change in
color and
ede)a o(
the
o)ental
(at
0arrows2
Page 2 o( 8
(page number not
for citation
purposes)
World
Journal of
Emergency
Surgery
2008, 3:30
Fistopat3olo
gical
e=amination
confirmed
t3e diagnosis
of omental
infarction
and
p3legmonous
acute
appendici!tis0
*3e
3istological
e=amination
re+ealed a
reddis3
infarc!tion of
t3e fatt#
tissue of t3e
greater
omentum0
*3e
omentum
contained
scattered
3emorr3ages
and t3e +es!
sels ;ere
mar<edl#
distended
;it3 blood0
DFig0 -E
*3e
postoperati+e
course ;as
une+entful
and t3e
patient ;as
disc3arged
on t3e fift3
postoperati+e
da#0
4mental
infarction is
an infre@uent
entit#0 'ts
presenta!tion
toget3er ;it3
intraoperati+
el# and
3istopat3olog
i!call#
confirmed
acute
appendicitis
is far more
uncommon0
*o t3e best of
our
<no;ledge,
t3is is t3e
first case in
t3e literature
reporting
suc3 unusual
association0
%epending
on t3e
causati+e
factor, t3is
clinical
problem can
be classified
as omental
infarction
;it3 torsion,
and
htt&:""wwww*
esorg"conten
t"3"1"30
omental
infarction
;it3out
torsion,
commonl#
<no;n as
idiopat3ic
omental
infarction
D*able ,E0
'n a recent
collecti+e
re+ie; of
nineteen
cases of t3e
idio!pat3ic
t#pe from t3e
last -. #ears
8/9, >-: of
t3e cases
occurred in
pediatric
patients0
Female
patients ;ere
affected onl#
in ,B: of t3e
cases0 4nl#
-,: of t3e
patients D>
out of ,6E
presented
;it3 fe+er,
and t3e mean
;3ite blood
cells count
;as
,-07//Cmm
/
0
Almost ?B:
of t3e cases
D,> out of
,6E ;ent to
t3e operating
room ;it3 a
diagnosis of
acute
appendicitis,
and /7: of
all cases
;ere
resol+ed b#
laparoscop#0
'n one 3alf of
t3e cases,
free
serosanguine
ous
peritoneal
fluid ;as
also present
at
e=ploration0
Among t3e
publis3ed
cases, our
patient 3as a
more at#pi!
cal
presentation
t3at t3ose
pre+iousl#
reported0 As
described
earlier, most
aut3ors
suggest acute
appendicitis
!igure $
Micrograp
h
shoing
the
histologic
al results
of the
infarcted
omentum#
9ote the
areas o(
(at
necrosis
and
li5ue(ac%
tive
changes
'here are
also
scattered
acute
in(la))ato
r1 cells
Page 3 o( 8
(page number not
for citation
purposes)
World Journal of Emergency
Surgery 2008, 3:30
htt&:""wwww*esorg"content"3"1"
30
%able ": &lassification of the
infarctions of the greater
omentum#
Omental infarction without
torsion:
Pri)ar1 04dio&athic in(arction
o( the greater o)entu)2
:econdar1: hernia,
h1&ercoagulabil1, &atholog1
vascular, &ol1globulia
Omental infarction with
torsion:
Pri)ar1
:econdar1: adherences,
c1sts, tu)or
as
preoperati+e
diagnosis,
but t3e
appendi= is
usuall# found
to be
macroscopica
ll# normal
eit3er at
e=ploration
or at
3istopat3olog
ical anal#sis
8>90
*3e e=act
etiolog# and
pat3ogenesis
of t3is
condition is
un<no;n0
"ome aut3ors
3a+e
suggested
t3at
congenitall#
anomalous
fragile blood
suppl# to t3e
rig3t lo;er
portion of t3e
greater
omentum
renders t3is
region prone
to inf!arction
8B90 4t3er
aut3ors 879
suggest a
different
embr#!onic
origin for t3e
rig3t side of
t3e greater
omentum
;it3 more
fragile blood
+essels
;3ic3 are
more
susceptible to
elongation
and
secondar#
occlusions0
"uc3 a t3eor#
could e=plain
t3e 3ig3
incidence
D6.:E of t3is
disease in t3e
rig3t side of
t3e greater
omentum0
Variations in
blood suppl#
to t3e rig3t
omental edge
associated
;it3 obesit#
or trauma,
o+ereating,
3#percoagula
bilit#,
coug3ing or a
sudden
c3ange in
position 3a+e
been
suggested as
predis!posing
factors 8B90
4t3er aut3ors
suggested
+enous
engorgement
after 3ea+#
meals or
+enous
elongation
pro!duced b#
e=cessi+e
;eig3t of t3e
greater
omentum as
a cause, since
t3e 3ig3er
pre+alence of
t3e s#ndrome
in t3e obese
population
8790
linicall#,
most patients
present ;it3
acute or
subacute
abdominal
pain0 *3e
pain ma# be
to t3e left or
rig3t side of
t3e midline
based on t3e
side of
omental
in+ol+ement0
Pain ma#
locali&e to
t3e upper or
lo;er
@uadrant of
t3e abdomen,
simulating
acute
appendicitis
D77:E or
c3ole!c#stitis
8B90 'n female
patients, t3e
entit# can
also mimic
g#necologic
problems0
ca<e!li<e soft
tissue mass0
Because of
omental fat,
t3e lesion is
3#perec3oic
at ultrasound
and of mi=ed
attenua!tion
due to fatt#
and no fatt#
elements on
computed
tom!ograp3#
8?90
Pat3ologicall
#, t3e rig3t
side of t3e
omentum is
affected in
most of
patients0 *3e
3istological
appearance
of omen!tal
infarction
differs ;it3
t3e duration
of insult0
'nitiall#,
3emorr3agic
infarction
;it3 fat
necrosis is
seen,
follo;ed b#
infiltration
b#
l#mp3oc#tes,
3istioc#tes,
and finall#,
fibroblasts,
resulting in
fibrosis and
scar
formation0
%ifferentiatio
n bet;een
torsion and
infarction is
not of
practical
significance
as t3e
management
remains t3e
same, i0e0
surgical
resection of
t3e infarcted
omentum,
and it is t3e
usual
treatment
;3en t3e
diagnosis is
not
establis3ed
preoperati+el
#0 Eit3er b#
open surger#
or
laparoscop#,
t3e rationale
for e=cision
rests on t3e
t3eo!retical
possibilit# of
ad3esions
forming
about t3e
infarct,
;3ic3 could
obstruct
nearb# bo;el
loops0
'diopat3ic
segmental
infarction of
t3e rig3t
sided greater
omentum
s3ould be
considered
e+en in t3e
presence of
acute
appendicitis
or ot3er intra
abdominal
pat3ologies
since it ma#
occur and
mimic t3e
basic
pat3ologic
condi!tion as
an associated
disease0
Furt3ermore,
e+en ;3en
ot3er +iscera
are found to
be normal at
e=ploration,
t3e omentum
s3ould be
inspected for
infarction,
especiall# if
free
serosanguine
ous
peritoneal
fluid is
present0
*3e p3#sical
findings are
+ariable but
usuall# t3ere
is ten!derness
in t3e rig3t
side of t3e
abdomen,
predominantl
# at t3e rig3t
lo;er
@uadrant0
P3#sical
e=amination
usuall#
elicits
locali&ed
tenderness
;it3 or
;it3out a
palpable
(mass(0
*emperature
is usuall#
normal or
slig3tl#
raised0
4ccasionall#,
t3e AB
count ma# be
ele+ated0
*3erefore,
clinicall#,
omental
infarction is
difficult to be
distin!
guis3ed from
appendicitis,
c3olec#stitis,
or adne=al
prob!lems0
"ince it is
rarel#
diagnosed
before
surger#, t3e
imaging fea!
tures of
omental
resection
3a+e been
seldom
described in
t3e
radiological
literature0
omputed
tomograp3#
andCor
ultrasound
can be
e=tremel#
3elpful in
establis3ing
t3e diagnosis0
Bot3 ma#
s3o; a ;ell
circumscribe
d, o+oid or
&onclusio
n
't is possible
t3at
infarction of
un<no;n
origin
in+ol+ing t3e
greater
omentum is
more
common t3an
is usuall#
t3oug3t0 Ae
emp3asi&e
t3at
idiopat3ic
segmental
infarc!tion of
t3e greater
omentum
s3ould be
included in
t3e
differential
diagnosis of
an# patient
;it3 rig3t
sided
abdominal
pain, and
inspection of
t3e omentum
s3ould be a
routine part
of
e=ploration
;3en a more
common
cause of
abdominal
complaint is
not readil#
ob+ious at
operation or
e+en in t3e
presence of
ot3er intra
abdomi!nal
conditions0
&onsent
(Aritten
informed
consent ;as
obtained
from t3e
patient for
t3e
publication
of t3is article
and
accompan#in
g
Page $ o( 8
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World Journal of Emergency
Surgery 2008, 3:30
htt&:""wwww*esorg"content"3"1"
30
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Ac(noledgements
'his stud1 was &artiall1 su&&orted
b1 grants o( the 4talian Association
(or
Cancer Research 0A4RC ; .ilan2
Authors than3 the secretar1, .rs
Aceto
Roberta, (or assistance in
&re&aring the )anuscri&t
References
,H,ush P: A case of
haemorrhage into the
greater omentum#
The Lancet 189!, ")*:28!
-H,
a
r
c
i
a

P
<
,

9
e
l
s
o
n

'
=
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