What are the causes and management of omental infarction?

Causes and Management of Omental Infarction

Omental infarction is a rare cause of acute abdomen with nonspecific signs that can be mistaken for other more common intra-abdominal pathologies. Conservative management with appropriate imaging should be recommended initially before considering surgical treatment in refractory cases. 1

Causes of Omental Infarction

• Primary (Idiopathic) Causes:

  • Obesity 2
  • Strenuous physical activity 2
  • Idiopathic omental torsion 3, 2
  • Anatomical variations in omental blood supply 4

• Secondary Causes:

  • Trauma 2
  • Previous abdominal surgery (delayed complication) 2
  • Hypercoagulable states 4
  • Vascular abnormalities affecting omental blood supply 3

Clinical Presentation

• Abdominal Pain:

  • Most commonly presents with nonspecific abdominal pain 1
  • Right iliac fossa pain (most common location) 1
  • Right upper quadrant pain (second most common) 1
  • Can also occur in epigastric area, lower abdomen, or left side 4
  • Average duration of symptoms before presentation is 2.7 days 1

• Associated Symptoms:

  • May mimic acute appendicitis, cholecystitis, or pancreatitis 3
  • Low-grade fever may be present 4
  • Nausea and vomiting are less common than in other acute abdominal conditions 1

Diagnosis

• Imaging:

  • Computed tomography (CT) with contrast is the gold standard for diagnosis 1, 4
  • Characteristic findings include an inflammatory mass containing fat and fluid 2
  • Ultrasound may show hyperechoic, non-compressible mass in the omentum 4

• Diagnostic Laparoscopy:

  • May be required when imaging is inconclusive 1
  • Allows direct visualization of the infarcted omentum 3, 5
  • Inspection of the omentum should be a routine part of exploration in suspected acute appendicitis 3

Management

• Conservative Management:

  • First-line approach for hemodynamically stable patients 1
  • Includes:
    • Analgesics for pain control 4
    • Anti-inflammatory medications 4
    • Close monitoring for clinical improvement 1
  • Successful in approximately 69% of cases 1
  • Trial period of 24-48 hours recommended before considering surgery 1

• Surgical Management:

  • Indicated for:
    • Failed conservative management with persistent symptoms 1, 4
    • Uncertain diagnosis despite imaging 3
    • Hemodynamic instability 1
  • Laparoscopic approach is preferred over open surgery 1, 3, 5
  • Procedure involves:
    • Excision of the infarcted omental segment (omentectomy) 1, 3
    • Inspection for other pathology 3

Outcomes and Prognosis

• Average hospital length of stay is 3.4 days 1
• No significant morbidity or mortality reported 1
• Self-limited course in most cases with conservative management 4
• Recurrence is rare after appropriate management 1

Important Clinical Considerations

• Omental infarction should be included in the differential diagnosis of acute abdominal pain at any site 4
• The incidence of omental gangrene presenting as acute appendicitis is approximately 1.1% 3
• Unnecessary operations can be avoided when omental infarction is diagnosed by imaging studies 4
• Laparoscopy offers both diagnostic and therapeutic benefits in cases of omental infarction 3, 5