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.