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farction of the great
omentum and acute
appendicitis: a rare
associationLuigi Battaglia*, Filiberto Belli, Alberto
Vannelli, Giuliano Bonfanti,
Gianfrancesco Gallino, Elia Poiasina,
Mario Rampa, Marco Vitellaro andErmanno Leo
Address: olo!rectal ancer "urger# $nit, %epartment of "urger#, Fonda&ione 'R"
('stituto )a&ionale dei umori(, +ia Vene&ian, ! Milan, -.//, 'tal#
Email: Luigi Battaglia* ! luigi0battaglia1istitutotumori0mi0it2 Filiberto Belli !
luigi0battaglia1istitutotumori0mi0it2
Alberto Vannelli ! luigi0battaglia1istitutotumori0mi0it2 Giuliano Bonfanti !
luigi0battaglia1istitutotumori0mi0it2
Gianfrancesco Gallino ! luigi0battaglia1istitutotumori0mi0it2 Elia Poiasina !
luigi0battaglia1istitutotumori0mi0it2
Mario Rampa ! luigi0battaglia1istitutotumori0mi0it2 Marco Vitellaro !
luigi0battaglia1istitutotumori0mi0it2
Ermanno Leo ! luigi0battaglia1istitutotumori0mi0it
* orresponding aut3or
Published: 29 October 2008Received: 31 August2008
World Journal of Emergency Surgery 2008,3:30
doi:10118!"1#$9%#922%3%30
Acce&ted: 29 October2008
'his article is available (ro): htt&:""wwww*esorg"content"3"1"30
+ 2008 attaglia et al- licensee io.ed Central /td'his is an O&en Access article distributed under the ter)s o( the Creative Co))ons
Attribution /icense htt&:""creativeco))onsorg"licenses"b"20, which &er)its
unrestricted use, distribution, and re&roduction in an )ediu), &rovided the original wor
is &ro&erl cited
Abstract
4dio&athic seg)ental in(arction o( the greater
o)entu) is an unco))on cause o( acute
abdo)en 'he etiolog is still unclear and the
s)&to)s )i)ic acute a&&endicitis 4ts
&resentation si)ultaneousl with acute
a&&endicitis is still )ore in(re5uent 6e
&resent a case o( a $#%ear old wo)an
without signi(icant &revious )edical histor,
ad)itted with an acute abdo)en, in which the
clinical diagnosis was acute a&&endicitis and
in who) an in(arcted seg)ent o( right side o(
the greater o)entu) was also (ound at
la&aroto) As the etiolog is unnown, we
highlighted so)e o( the &ossible theories, and
e)&hasi7e the i)&ortance o( o)ental
in(arction even in the &resence o( acute
a&&endicitis as a coincident intra&eritoneal
&athological condition
Revie4mental 'nfarction, t3e result of
impaired perfusion to t3e greater
omentum, is a rare entit#0 First
described b# Bus3 in 567 89, t3eincidence of idiopat3ic segmental
infarction of t3e greater omentum is
estima
ted to
be
.0
of t3e
total
laparo
tomie
s
perfor
med
foracute
abdo
men
8-90
E+en
t3oug
3
more
t3an
..
cases3a+e
been
report
ed in
t3e
literat
ure,
its
associ
ation
;it3
acute
appendicitis
3as
been
rarel#
docu
mente
d0
More
intere
stingl
#, t3is
case
alsopresen
ted in
a
femal
e
patien
t,
;3ic3
ma
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3e purpose of t3is report is to
describe our first e=peri!ence ;it3 t3is
condition0 E+en t3oug3 t3e etiolog# is
un?!#ear!old ;oman presented to t3e
emergenc# depart!ment complaining
of rig3t lo;er abdominal pain of >5
3ours of duration along ;it3 3ig3
fe+er and nausea ;it3!out +omiting0
3e patient 3ad no rele+ant pre+ious
medi!cal 3istor#0 3e pain started at
t3e rig3t paraumbilical and
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ad3esions,
resected and
remo+ed0
Fur!t3er
inspection
s3o;ed no
ot3er
abnormalities
0 3ere!fore,
a partial
omental
resection and
a base!apical
appendectom
# ;ere
performed0
!igure "
Macroscopicalappearance oftheinfarctedarea ofthegreateromentu
m foundduringlaparoto
my foracuteappendicitis#ote thechange incolor andede)a o(theo)ental
(atarrows
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purposes)
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WorldJournal ofEmergencySurgery2008,3:30
istopat3olo
gical
e=amination
confirmed
t3e diagnosis
of omental
infarction
and
p3legmonous
acute
appendici!tis0
3e
3istological
e=amination
re+ealed a
reddis3
infarc!tion of
t3e fatt#
tissue of t3e
greater
omentum0
3e
omentum
contained
scattered
3emorr3ages
and t3e +es!
sels ;ere
mar
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also present
at
e=ploration0
Among t3e
publis3ed
cases, our
patient 3as a
more at#pi!cal
presentation
t3at t3ose
pre+iousl#
reported0 As
described
earlier, most
aut3ors
suggest acute
appendicitis
!igure $
Micrographshoingthehistological resultsof the
infarctedomentum#ote the
areas o((atnecrosisandli5ue(ac%tivechanges'here arealsoscattered
acutein(la))ator cells
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purposes)
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World Journal of Emergency
Surgery 2008,3:30
htt&:""wwww*esorg"content"3"1"30
%able ": &lassification of theinfarctions of the greateromentum#
Omental infarction without
torsion:
Pri)ar 4dio&athic in(arctiono( the greater o)entu)
econdar: hernia,h&ercoagulabil, &athologvascular, &olglobulia
Omental infarction with
torsion:
Pri)ar
econdar: adherences,csts, tu)or
aspreoperati+e
diagnosis,
but t3e
appendi= is
usuall# found
to be
macroscopica
ll# normal
eit3er at
e=ploration
or at
3istopat3olog
ical anal#sis8>90
3e e=act
etiolog# and
pat3ogenesis
of t3is
condition is
un
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+enous
engorgement
after 3ea+#
meals or
+enous
elongation
pro!duced b#
e=cessi+e
;eig3t of t3e
greateromentum as
a cause, since
t3e 3ig3er
pre+alence of
t3e s#ndrome
in t3e obese
population
8790
linicall#,
most patients
present ;it3acute or
subacute
abdominal
pain0 3e
pain ma# be
to t3e left or
rig3t side of
t3e midline
based on t3e
side of
omental
in+ol+ement0
Pain ma#locali&e to
t3e upper or
lo;er
@uadrant of
t3e abdomen,
simulating
acute
appendicitis
D77 or
c3ole!c#stitis
890 'n female
patients, t3e
entit# canalso mimic
g#necologic
problems0
ca
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t3e infarcted
omentum,
and it is t3e
usual
treatment
;3en t3e
diagnosis is
not
establis3ed
preoperati+el#0 Eit3er b#
open surger#
or
laparoscop#,
t3e rationale
for e=cision
rests on t3e
t3eo!retical
possibilit# of
ad3esions
forming
about t3e
infarct,;3ic3 could
obstruct
nearb# bo;el
loops0
'diopat3ic
segmental
infarction of
t3e rig3t
sided greater
omentum
s3ould be
considered
e+en in t3e
presence of
acute
appendicitis
or ot3er intra
abdominal
pat3ologies
since it ma#occur and
mimic t3e
basic
pat3ologic
condi!tion as
an associated
disease0
Furt3ermore,
e+en ;3en
ot3er +iscera
are found to
be normal at
e=ploration,t3e omentum
s3ould be
inspected for
infarction,
especiall# if
free
serosanguine
ous
peritoneal
fluid is
present0
3e p3#sicalfindings are
+ariable but
usuall# t3ere
is ten!derness
in t3e rig3t
side of t3e
abdomen,
predominantl
# at t3e rig3t
lo;er
@uadrant0
P3#sical
e=aminationusuall#
elicits
locali&ed
tenderness
;it3 or
;it3out a
palpable
(mass(0
emperature
is usuall#
normal or
slig3tl#
raised04ccasionall#,
t3e B
count ma# be
ele+ated03erefore,
clinicall#,
omental
infarction is
difficult to be
distin!
guis3ed from
appendicitis,
c3olec#stitis,
or adne=al
prob!lems0
"ince it is
rarel#
diagnosed
before
surger#, t3e
imaging fea!
tures of
omental
resection
3a+e been
seldom
described in
t3eradiological
literature0
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omputed
tomograp3#
andCor
ultrasound
can be
e=tremel#
3elpful in
establis3ing
t3e diagnosis0
Bot3 ma#s3o; a ;ell
circumscribe
d, o+oid or
&onclusion't is possible
t3at
infarction of
un
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g
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World Journal of Emergency
Surgery 2008,3:30
htt&:""wwww*esorg"content"3"1"30
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&ompeting interests3e aut3ors declare t3at t3e#
3a+e no competing interests0
Authors' contributionsL
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Ac(noledgements'his stud was &artiall su&&ortedb grants o( the 4talian Association(or
Cancer Research A4RC ; .ilanAuthors than the secretar, .rsAceto
Roberta, (or assistance in&reå the )anuscri&t
References
H ush P: A case ofhaemorrhage into thegreater omentum#The Lancet 189!,")*:28!
-H arciaP