Discussion
Omental torsion, first described by Eitel in 1899, is a rare cause of
acute abdomen with unknown etiology.(2) It affects males twice as
frequently as females, usually between the fourth and fifth decade of
life. It is more common in obese patients.(1) It usually presents with
nonspecific symptoms and signs mimicking other abdominal pathologies,
especially acute appendicitis. Thus, its diagnosis has been usually made
intraoperatively with only 0.6-4.8% of cases being preoperatively
diagnosed.(5) However, its preoperative diagnosis is more commonly
established nowadays after the liberal use of computed tomography in the
causalities. (3)
The omentum is a peritoneal fold hanging between the stomach and the
transverse colon. It divides into right and left omentum. The
right-sided omentum is longer, more mobile, and consequently, more
common to be twisted along its blood supply causing omental torsion.
Omental fat deposition occurs during childhood and is proportionally
related to the overall fat.(1)
When the omentum twists around its long axis, it leads to venous
obstruction with resultant edema and arterial compromise leading to
abdominal manifestations.(5) Omental torsion may lead to omental
infarction; however, it is considered a different clinical entity.(6)
Omental torsion is classified into primary and secondary. Primary
omental torsion occurs without identifiable predisposing abnormalities,
while secondary torsion occurred on top of an intra-abdominal pathology
as hernias, omental cysts, tumors, or adhesions. Risk factors for
omental torsion include obesity, trauma, anatomical variations, and a
sudden increase in intra-abdominal pressure.(2)
Patients with omental torsion usually present with sudden localized
abdominal pain aggravated by a sudden movement which may be associated
with nausea and vomiting. On examination, there is right-sided
tenderness with rebound tenderness. Temperature, total leukocytic count,
and inflammatory markers may be slightly elevated or normal. Otherwise,
laboratory findings are nonspecific that may delay the diagnosis and
management. Its CT findings include a well-circumscribed fatty mass with
dilated thrombosed veins.(1)
Due to its rarity, the treatment of choice remains controversial with no
clear consensus or guidelines, especially with absence of prospective
comparative studies.(1,3) Some authors have recommended surgical
management with resection of the twisted omentum. Laparoscopic
management is preferred rather than exploration laparotomy as it is
associated with better visualization of the abdominal cavity, less
postoperative pain, and wound-related complications. It provides clear
precise diagnosis, excludes other differential diagnoses, speeds up the
recovery by resecting the affected twisted omentum and eliminating the
cause of abdominal pain, and thus, decreases the hospital stay and
costs.(2) However, other experts have suggested the conservative
management, including analgesia and prophylactic antibiotics, based on
the natural history of the disease as a self-limited benign condition,
hence, avoiding the operative complications. They argue that the recent
advances and wide availability of CT allow reliable diagnosis, exclusion
of other pathologies and, consequently, substitute the role of
diagnostic laparoscopy. The administration of prophylactic antibiotics
is justified to guard against hypothetic possibility of abscess
formation.(7) And so, laparoscopic management is only reserved for cases
of failed conservative management or cases with an unclear
diagnosis.(1-3,7,8) .
In our case, the patient presented for the second time within one week
with on-and-off right lower quadrant moderate abdominal pain. He was
tachycardic with low-grade fever and his abdominal examination was
suggestive of acute appendicitis. His laboratory findings showed
slightly elevated leukocytosis and inflammatory markers. Our
differential diagnosis at that point was acute appendicitis; however,
the long duration (four days) of symptoms was not in line with his
examination and laboratory findings. His CT scan confirmed the presence
of omental torsion and excluded acute appendicitis and other
pathologies. Therefore, we opted to start with a trial of a conservative
approach with a low threshold to perform laparoscopic resection. We
elected to administer wide-spectrum antibiotics to cover possible
pathogens that may cause abscess. The close follow up, by serial
examination and laboratory works, was crucial to early pick up any signs
of sepsis. Fortunately, he responded well and promptly to the
conservative management and was discharged within one week.