The patient and his story
According to Viennese doctors, the man was hospitalized due to nausea and vomiting which had lasted for two days. Esophageal carcinoma was known and was surgically removed in 2016 (esophageal resection with lymphadenectomy and esophagogastrostomy). The patient had not presented with a new tumor in the last four years.
Results, diagnosis and evolution
- CRP
- White blood cell count 8.15 × 109/L (normal 4 to 10 × 109/L).
- Abdominal wall not painful to pressure.
- Ultrasound of the abdomen: two areas of the upper abdomen under the abdominal wall, poor in echo and specific for the tumor.
- Computed tomography with contrast: two “masses” equivalent to fat, presenting a dense halo of soft parts in the greater omentum.
According to the authors, the morphology of the scan was pathognomonic of an omental infarction, which is why the doctor decided against a biopsy. The analysis of the previously performed scans revealed that this omental infarction was already detectable one year after the surgical intervention, “ so that the acute disturbances clearly could not be attributed to the omental infarction “. The patient reportedly received symptomatic treatment and returned home.
Discussion
According to the authors, omental infarcts can be clearly distinguished from other fatty lesions of the abdomen, such as lipomas, thanks to their typical morphology and their location in the omentum.
In a retrospective case series, the cause of infarctions was unknown in 53% of cases and abdominal surgery had preceded this situation in 47% of cases. In other retrospective case series, omental infarctions would be described as a non-rare change after colon resection or gastrectomy. The incidence is estimated at 2.3% after laporoscopic gastrectomy. The cause of the occurrence of omental infarction after gastrectomy would be the division of the branches of the right gastroepiploic artery necessary during this procedure. According to a systematic review, treatment is most often conservative. In the present case, there was certainly no gastrectomy, but the stomach was mobilized to replace the esophagus, as usual with section of the gastrocolic ligament, which almost completely deprives the greater omentum of its vascularization. This results in a decrease in perfusion of the omentum, usually clinically insignificant, which then retracts.
In 2013, Ulm doctors around Dr. Stefan A. Schmidt (Clinic for Diagnostic and Interventional Radiology, Ulm University Clinics) also reported a patient with an omental infarction, but without a previous surgical history. In this case, it was a 61-year-old man who, according to the authors, presented with upper to mid-abdominal pain on the right side that had persisted and intensified for three years. days. Previously, he had lifted several heavy objects during a move. In the present case, the cause of the omental infarction was twisting of the vessels. The patient was treated conservatively; After three days, he no longer reported pain.
In principle, according to Schmidt and colleagues, greater omentum infarctions can be divided into a primary group and a secondary group. In the case of a primary infarction, it would be a segmental necrosis due to torsion of the omentum without other pathology. On the other hand, secondary infarctions would occur in the event of associated pathologies, most often postoperatively by rotation of the structures in the event of adhesions as well as in the case of peritoneal carcinomatosis.
Primary twisting is accomplished by rotating part of the array around the longitudinal axis at a fixed point. According to Ulm doctors, predisposing factors are network contour abnormalities, irregular reticular vessels, mechanical impairment (blunt abdominal trauma), coughing and physical overexertion. Primary torsions occur primarily in the right side of the abdomen. The secondary torsion would be carried out by rotation of a part of the network between its base and a second fixed point. First of all, these are pre-existing pathologies, such as tumors, cysts, inflammatory changes, scar tissue and external hernias.
In their case, the Ulm authors started from the principle that it was a primary torsion of the omentum, because the occurrence was in direct temporal relation with a significant physical effort and that no antecedent was known.
This case study was originally published on Univadis.de.
