Muhammad Abdullah Khalid a, Mohammed Amir (Section Head) b

a
Postgraduate trainee Department of Surgery Shifa International Hospital,
Islamabad
b
Professor Of Surgery/Principal Shifa College of Medicine.

Abstract
BACKGROUND: Intraperitoneal Focal Fat Infarction (IFFI) is a rare cause of acute
abdomen and can be neglected frequently. There are two types, Omental Torsion
and Epiploic Appendagecitis. Omental Torsion has been classified into Primary
and Secondary depending on the etiology and can involve greater or lesser
omentum.

CASE DESCRIPTION: We present a case of 19 years old male who presented to

Emergency department with severe abdominal pain in epigastrium as well as right
ileac fossa. Ultrasound and rest of laboratory investigations failed to demonstrate
any abnormality. Clinical diagnosis of acute appendicitis made, but epigastric pain
remained unexplained. High resolution CT scan did not pick any pathology.
Diagnostic Laparoscopy was done which diagnosed lesser omental infarction and
acute appendecits. Patient was successfully managed by Laparoscopic Surgery
and his postoperative recovery was uneventful.

CONCLUSION: Symptoms which are not explained by a single pathology should be

thoroughly investigated through imaging. CT Scan is the best investigation to
detect such rare conditions. Laparoscopic surgery is an effective and safe
approach for small segmental omental torsion.

Keywords: Abdominal Pain, Omentum, Torsion, CT Scan, Laparoscopic Surgery

Introduction
In 1999 van Breda Viersmann introduced the term IFFI (Intraperitoneal
Focal Fat Infarction) to widely describe various conditions like torsion/infarction
of greator or lesser omentum and epiploic appendage. Their symptoms differ
depending on various anatomical positions but focal fat tissue necrosis is common
in all. [1,2] Eitel described the Omental Torsion in 1899. A small number of cases
have been reported since then. Men are 5 times more vulnerable than women as
the latter can store more adipose tissue. Only 0.1 % cases have been reported in
children. [3]

Acute appendicitis is a frequent cause of acute abdomen. Typically

presents with right ileac fossa pain, tenderness and guarding on
examination.

We are presenting a case with a rare combination of pathologies i.e. Lesser

Omental Infarction and acute appendicitis.
Case Report
A 19 years old male presented to Emergency Department of our hospital
with complaints of abdominal pain which initially started in epigastric region and
later on involved right ileac fossa since past 4 days. Pain was gradual in onset,
colicky in nature, reached to score 7/10 and relieved by oral analgesics. He did not
refer any complaints of nausea, vomiting, diarrhea, fever or urinary symptoms.

On physical examination his blood pressure was 110/70 mmHg, heart rate
of 85 beats per minute, respiratory rate of 20 breaths per minute and
temperature of 37 °C. On palpabtion of the abdomen he had tenderness and
guarding in the epigastric region as well as right ileac fossa.

Labaratory investigations revealed total leukocyte count of 9300, 12.8 g/dl

Haemoglobin, 240000 platelets, 108 mg/dl glucose and 0.86 mg/dl creatinine. C -
reactive protein was 1.43. Serum electrolytes were normal and Urine dipstick was
negative.

A computed tomography (CT) scan of abdomen and pelvis was done which
was not contributive to the diagnosis. Usual analgesics did not relieve his pain. So,
we administered opioids.

As patient’s clinical condition was not improving and diagnosis was

uncertain, we decided to perform Diagnostic Laparoscopy. A segment of lesser
omentum attached to the lesser curvature of stomach was rotated at 720 degrees
around its own axis in the clockwise direction; part of omentum distal to level of
rotation was gangrenous. There was incidental acute appendicitis. (Figure 1,
Figure 2, Figure 3, Figure 4)

Therefore, Laparoscopic Partial Omentectomy and Appendectomy was

performed. The specimens were sent for histopathology. There was no other
pathology detected into the abdominal cavity on laparoscopy. Patient remained
stable postoperatively and was discharged home on 1st postoperative day. Patient
came for follow up after one week and had recovered completely.
Figure 1: a. Liver b. Gall Bladder c. Healthy omentum d. Twisted pedicle e. Necrosed Omentum
Figure 2
Figure 3
Discussion
Torsion of the lesser omentum is an extremely rare condition which presents as
acute abdomen. It is an infrequent entity appearing as IFFI.

Donhauser and Loke classified the omental torsion into “primary” and
“secondary”. 4 Secondary torsion is relatively more common than primary torsion
and is usually associated with tumours, cystic lesions, hernias and intra abdominal
inflammatory processes. 5

It can also be classified as Unipolar- torsion in which proximal part of the

omentum remains fixed and Bipolar- torsion in which proximal and distal part of
the omentum remains fixed.6

Its diagnosis is difficult as there are no characteristic signs and symptoms. It can
mimic as variety of other pathologies like appendicitis, perforated duodenal ulcer,
cholecystitis and diverticulitis.1,2,6

The pathophysiology of primary omental torsion is not clear. Adams classified the
pathogenesis of the primary omental torsion into two types of factors:

Predisposing factors – Anomalies of omental blood vessels, obesity

Precipitating factors – Hyperperistalsis, sudden changes of position like
twisting movements of body, trauma, overeating and use of laxatives 7

Clinical presentation may include nausea, vomiting, abdominal pain and low grade
fever. It may cause signs of peritoneal irritation depending upon its location into
the abdominal cavity. Leukocytosis may or may not be present. 8

As clinical diagnosis of this pathology is difficult so preoperative Ultrasound and

contrast enhanced CT Scan must be considered, though in many cases radiological
findings may miss the diagnosis. 7,9 In our case, contrast enhanced CT could not
pick any of the pathologies and we planned diagnostic laparoscopy on the basis of
clinical findings which helped to make the diagnosis.

In cases where imaging does not give the diagnosis, diagnostic laparoscopy is the
procedure of choice for diagnosis and treatment of omental torsion.10,11 In
patients where the diagnosis is not picked on imaging, diagnostic laparoscopy
proceeding to laparotomy is the management of choice. It is useful for diagnostic
as well as therapeutic purposes allowing the excision of affected part of omentum
through minimally invasive access or small abdominal incision. 11

Competing interests
The authors declare that there are no competing interests

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