Rare causes of acute abdomen and review of literature: Primary/secondary omental torsion, isolated segmental omental necrosis, and epiploic appendagitis

Abstract

Background: Primary/secondary omental torsion (POT/SOT), isolated segmental omental necrosis (ISON), and primary epiploic appendagitis (PEA) are rare causes of acute abdominal pain that often lead to misdiagnosis. Although the differential diagnosis may vary according to the localization and severity of the pain, and associated symptoms such as nausea-vomiting and fever, depending on the disease and site of involvement, the character of the pain is generally similar and in a continuous form. Depending on pain localization, it can mimic different clinical pictures such as acute appendicitis, acute diverticulitis, ovarian pathologies, urinary tract stones and acute cholecystitis, and patients are often diagnosed after surgical exploration. With the increased availability of computed tomography and awareness of these diseases, more patients can be diagnosed in the preoperative process and unnecessary operations can be avoided. In particular, PEA is a self-limiting local inflammatory disease and can often be managed conservatively. For all diagnoses, the surgical treatment option is local excision of the relevant epiploic appendix or omental segment, preferably laparoscopically. The most common surgical indication is diagnostic confusion and the second is persistent pain.

Methods: The data of patients followed up and treated for a diagnosis of POT, SOT, ISON or PEA between 2006 and 2021 were recorded in a specially prepared database. The demographic characteristics of the patients, and the data regarding the diagnosis and treatment process were evaluated retrospectively and discussed in the light of the relevant literature.

Results: The reason for hospitalization and treatment in 12 of the 42 patients included in the study was necrosis of a part of the omentum. Of these patients, 4 were followed up and treated with a diagnosis of POT, 3 with SOT, 5 with ISON and 30 with a diagnosis of PEA. Thirty-three of the patients were diagnosed preoperatively, and 9 intraoperatively, 22 patients were operated on, and 20 patients with PEA were treated conservatively. After surgical or medical treatment, all the patients were discharged without complications. In the comparisons between the patients, no significant difference was observed in terms of clinical and laboratory findings.

Conclusion: POT, SOT, ISON and PEA should be considered in the differential diagnosis of patients with acute abdominal findings. In patients with PEA diagnosed in the preoperative period, a conservative approach should be considered first. In patients with a diagnosis of POT, SOT, and ISON, a surgical or conservative approach should be evaluated according to the patient's clinical condition.

Figure 1

Intraoperative and piece images of primary/secondary omental torsion. (a-d) Primary omental torsion, (e) secondary omental torsion due to intra-abdominal mass lesion.

Figure 2

Omental necrosis histopathological examination. Inflammation (a) and bleeding areas (b) can be observed in the omentum (hematoxylin and eosin, ×40).

Figure 3

(a, b) Macroscopic view of isolated segmental omental necrosis.

Figure 4

(a, b) Intraoperative and computed tomography images of primary epiploic appendagitis.

Figure 5

Histopathological examination of primary epiploic appendagitis. Congestion (a) and acute inflammation findings (b) in the epiploic appendages in the colon wall (hematoxylin and eosin, ×40).