What are the management guidelines for omental infarction?

Management Guidelines for Omental Infarction

Conservative management with appropriate analgesia and monitoring should be the first-line approach for omental infarction, with surgical intervention reserved for cases that fail to improve within 24-48 hours or have worsening symptoms. 1

Clinical Presentation and Diagnosis

Omental infarction typically presents with:

• Nonspecific abdominal pain, most commonly in the right iliac fossa or right upper quadrant 1
• Pain duration averaging 2-3 days before presentation 1
• Possible mimicking of more common conditions like appendicitis or cholecystitis 2
• Can occur at any site in the abdomen where the greater omentum is located, including left side and epigastric area 2

Diagnosis is primarily made through:

• Computed tomography (CT) scan - showing characteristic inflammatory mass containing fat and fluid 3
• Diagnostic laparoscopy when imaging is inconclusive 1

Management Algorithm

First-line Management (0-48 hours):

• Conservative approach:
  • Adequate analgesia for pain control
  • Monitoring of vital signs and symptoms
  • Supportive care 2
  • Appropriate imaging (CT scan) to confirm diagnosis 1

Indications for Surgical Intervention:

• Failure to improve with conservative management within 24-48 hours 1
• Persistent or worsening abdominal pain despite adequate analgesia 2
• Hemodynamic instability
• Signs of peritonitis or sepsis

Surgical Approach:

• Laparoscopic omentectomy is the preferred surgical approach when intervention is required 4
• Resection of the infarcted omentum 4
• Average operative time: approximately 48 minutes 4

Patient Characteristics and Risk Factors

• More common in males 4
• Often affects preadolescent children and adults (mean age 51.1 years in adults) 1, 4
• Obesity is a significant risk factor 3, 4
• Other predisposing factors include strenuous activity and trauma 3

Outcomes and Prognosis

• Generally self-limited course with good outcomes 2
• Average hospital length of stay: 3.4 days 1
• No significant morbidity or mortality reported 1
• Prompt resolution of symptoms following either conservative management or surgical intervention 4

Important Considerations

• Omental infarction can occur at any site in the abdomen, not just the right side as previously thought 2
• CT diagnosis can prevent unnecessary surgical interventions 5
• Even when laparoscopy is performed, non-resection management may be considered in select cases 5
• In pediatric patients, the condition occurs predominantly in obese preadolescent males 4

Common Pitfalls to Avoid

• Misdiagnosing as appendicitis or cholecystitis, leading to unnecessary appendectomy 2
• Failing to include omental infarction in the differential diagnosis of acute abdominal pain 2
• Rushing to surgery without an adequate trial of conservative management 1
• Not recognizing that omental infarction can occur on the left side of the abdomen 2

By following these guidelines, clinicians can effectively manage omental infarction while avoiding unnecessary surgical interventions in cases that can be successfully treated conservatively.