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Letters to the Editor

Indian Pediatrics 2005; 42:613-614

Primary Torsion of the Greater Omentum


Primary or idiopathic torsion of the greater omentum (TGO) is an uncommon cause of acute abdominal pain in children. A 12-year-old boy presented with abdominal pain for 24 hours, anorexia, nausea and low-grade fever. The pain was localized in the right lower quadrant of the abdomen. Physical examination revealed abdominal tenderness and muscle guarding in the right abdomen. The leukocyte count was normal with a left shift (WBC: 7800/mm3, neutrophils 92%). The hematocrit was 37.4% and platelets count 2,26,000/µL. Ultrasonographic imaging was obtained but the findings were non-specific (small amount of fluid in the space of Douglas).

We suspected acute appendicitis, so emergency laparotomy was performed by Lanz incision, during which the presence of free intra-abdominal serosanguinous fluid was noted. The appendix had a normal appearance. Torsion was observed in the greater omentum, with necrosis of its distal part. This part was excised. Appendectomy was also performed. Pathology revealed an acute hemorrhagic infarct and fat necrosis. The boy recovered without any complications.

Primary omental torsion was first reported by Eitel in 1899 , and since then, fewer than 250 cases have been reported, mostly in adults. It has been estimated that 0.05-0.1% of children undergoing laparotomy for suspected appendicitis have primary omental torsion(1,3). TGO is a rare cause of abdominal pain in children and it has no distinguishing features to separate it from other causes of surgical abdomen, especially from acute appendicitis. It usually affects children older than 3 years of age, due to the increase in omental fat deposition as the child grows(4).

Torsion may be primary or secondary. In primary torsion, a mobile segment of omentum rotates around a proximal fixed point in the absence of any associated intra-abdominal pathology. If the mass is not excised it becomes atrophic and fibrotic and, on rare occasions, the pedicle may even auto-amputate, leading to automatic clinical regression(3). Secondary torsion occurs in the presence of lesions such as cysts, hernias, tumors and adhesions or congenital attachments and is believed to be more common than primary TGO(5).

The presentation of primary TGO seems to be less acute compared to other causes of surgical abdomen. The diagnosis is usually made at laparotomy or by laparoscopy. Treatment consists of resection of the affected portion of omentum. Appendectomy is performed at the same time, as it minimizes postoperative confusion and future diagnostic dilemmas. No postoperative recurrences are reported.

Chrysostomos Kepertis,
Georgios Koutsoumis,

Department of Pediatric Surgery,
Aristotle University of Thessaloniki,
General Hospital "Georgios Gennimatas",
Thessaloniki, Greece.
E-mail: [email protected]  

References

1. Phillips BJ, Mazaheri MK, Matthews MR, Caruso DM, Fujii TK, Schiller WR. Imitation appendicitis: primary omental torsion. Pediatr Emerg Care 1999; 15: 271-273.

2. Helmrath MA, Dorfman SR, Minifee PK, Bloss RS, Brandt ML, DeBakey ME. Right lower quadrant pain in children caused by omental infarction. Am J Surg 2001; 182: 729-732.

3. Valioulis I, Tzalas D, Kallintzis N. Primary torsion of the greater omentum in children–A neglected cause of acute abdomen. Eur J Pediatr Surg 2003; 13: 341-343.

4. Theriot JA, Sayat J, Franco S, Buchino JJ. Childhood obesity: a risk factor for omental torsion. Pediatrics 2003; 112: 460-462.

5. Cervellione RM, Camoglio FS, Bianchi S, Balducci T, Dipaola G, Giacomello L, et al. Secondary omental torsion in children: report of two cases and review of the literature. Pediatr Surg Int 2002; 18: 184-186.

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