Anisau, Aliaksandr

Desimpel, Julie

Kindt, Karolina

Petré, Carine

Vanhoenacker, Filip

English

Ghent University Academic Bibliography

Case 15420 Omental infarction in the postpartum periodAliaksandr Anisau , Carine Petré , Karolina Kindt , Julie Desimpel , Filip Vanhoenacker 1, 2 1 1 1, 3 1,2, 31. General Hospital AZ Sint-Maarten Duffel-Mechelen, Leopoldstraat 2, B-2800 Mechelen,Belgium.2. University Ghent, Department of Medicine and Health Sciences.3. University Hospital Antwerp, University Antwerp, Department of Radiology, University HospitalAntwerp; Wilrijkstraat, 10, 2650 Antwerp, Belgium; Email:filip.vanhoenacker@telenet.be University Hospital Antwerp  Abdominal Imaging Section: 2018, Jan. 20 Published: 30 year(s), femalePatient:Clinical HistoryA woman who gave birth 9 days ago by uncomplicated vaginal partus presents with subacute,gradually worsening epigastric pain. Further clinical history is unremarkable, except for chronicpyrosis. Clinical examination revealed epigastric tenderness without peritoneal irritation. Bloodanalysis showed moderate leucocytosis and strongly elevated CRP. No fever was present.Imaging FindingsAbdominal ultrasound showed a heterogenic lesion in the epigastric part of the greater omentumconsisting of concentrically alternating layers of hyper- and hypoechogenity (figure 1). Subsequentcontrast-enhanced CT of the abdomen confirmed an ill-defined ovoid lesion with a whirled patternof concentric alternating layers of fatty and soft tissue attenuation (figures 2a and 2b). The was nocontinuity with the transverse colon and the colonic wall was not thickened (figure 2c). There was amild diffuse infiltration of the intraperitoneal fat (figures 2a and 2b, red arrowheads).DiscussionOmental infarction is a rare condition affecting adults more often than children, with apredominance in young and middle aged women [1, 2, 3]. A common mechanism is omental torsion[1, 2]. The condition can be divided into primary and secondary infarction [4]. Hypercoagulablestate, obesity and vasculitis are predisposing factors [1, 4]. Precipitating factors include overeating,overexertion and trauma [1, 4]. Secondary omental infarction occurs because of mechanicaldistortion or manipulation of the omentum, following abdominal or pelvic surgery [1, 3]. Pregnancyand puerperium put females more at risk because of hormone-induced hypercoagulable state inaddition to mechanical distortion of the omentum by the gravid uterus [2, 4].Symptoms and signs are unspecific [1]. Patients present with acute or subacute abdominal pain,more often right-sided [1, 5]. A low grade fever and elevated inflammatory parameters may bepresent [1, 2]. Palpation often reveals localized tenderness and sometimes a palpable lump [4, 5].Other symptoms include nausea, vomiting, anorexia and diarrhoea [1]. Ultrasound may reveal a predominantly hyperechoic omental lesion, but unfortunately lackssensitivity [6].CT scan is the most appropriate tool to diagnose omental infarction and rules out other causes ofacute abdomen in emergency settings. Typically, an ill-defined, heterogeneous, fat-containinglesion between the anterior abdominal wall and the transverse or ascending colon is seen [1, 3]. Theshape is variable and may be either ovoid, cakelike or triangular [1, 3]. If the infarction is secondaryto torsion, there is a whirled pattern of concentrically arranged soft tissue strands inside the fattymass [1, 2, 3]. Secondary omental infarctions tend to be larger and denser than the primary [1, 4].Omental torsion occurs more often at the right side of the omentum, probably because of its largersize and greater mobility [1].Treatment of an omental infarction is essentially conservative, but surgery is indicated in case ofcomplications such as abscess formation or bowel obstruction [1, 4].The CT findings may persist for years, but the lesion will usually shrink over time. Primary omentalinfarctions tend to remain ill-defined, while the secondary tend to develop a well-definedhyperdense rim [1, 4].In conclusion, in the appropriate clinical setting and in presence of typical imaging findings ofomental infarction, CT may suggest the correct diagnosis, obviating surgical intervention.Final DiagnosisOmental infarctionDifferential Diagnosis ListAppendagitis eiploica, Omental metastases, Diverticulitis, Other conditions causing stranding ofintra-abdominal fat as (mesenteric) panniculitisFiguresFigure 1 Abdominal ultrasound, axial imageIll-defined lesion, containing a whirled pattern of alternating concentric layers ofhyperechogenicity (black arrowheads) and hypoechogenicity (white arrowheads). © AZ Sint-Maarten, Department of Radiology, Mechelen, Belgium. Area of Interest: Abdomen; Emergency;  Imaging Technique: Ultrasound;  Procedure: Diagnostic procedure;  Special Focus: Acute; Ischaemia / Infarction; Figure 2 Contrast enhanced CT of the abdomen, soft tissue windowOvoid lesion in the greater omentum with ill-defined margins and a whirling pattern ofalternating concentric layers of fat and soft tissue attenuation (red oval). Mild diffuseinfiltration of the intraperitoneal fat (red arrowheads). © AZ Sint-Maarten, Department of Radiology, Mechelen, Belgium Area of Interest: Abdomen; Emergency;  Imaging Technique: CT;  Procedure: Diagnostic procedure;  Special Focus: Acute; Ischaemia / Infarction; Ovoid lesion in the greater omentum with ill-defined margins and a whirling pattern ofalternating concentric layers of fat and soft tissue attenuation (red oval). Mild diffuseinfiltration of the intraperitoneal fat (red arrowheads). © AZ Sint-Maarten, Department of Radiology, Mechelen, Belgium Area of Interest: Abdomen; Emergency;  Imaging Technique: CT;  Procedure: Diagnostic procedure;  Special Focus: Acute; Ischaemia / Infarction; Ovoid lesion in the greater omentum with ill-defined margins, heterogeneous - partly fattycontent (red circle). There is no continuity with the transverse colon and the colonic wall isnot thickened (green arrow). © AZ Sint-Maarten, Department of Radiology, Mechelen, Belgium Area of Interest: Abdomen; Emergency;  Imaging Technique: CT;  Procedure: Diagnostic procedure;  Special Focus: Acute; Ischaemia / Infarction; References[1] Singh AK, Gervais DA, Lee P, Westra S, Hahn PF, Novelline RA, Mueller PR (2006) Omentalinfarct: CT imaging features Abdom Imaging 31:549-554[2] Tachezy M, Grotelüschen R, Gebauer F, Marx AH, Izbicki JR, Kaifi JT (2010) Omentalinfarction in the postpartum period: a case report and a review of the literature J Med Case Rep4:368[3] Naffaa LN, Shabb NS, Haddad MC (2003) CT findings of omental torsion and infarction: casereport and review of the literature Clin Imaging 27:116-118[4] Choh NA, Shera TA, Jabeen S, Ashraf O, Khan AM, Shaheen FA, Robbani I (2017) Primaryand secondary omental infarction: A 5-year experience in a tertiary care hospital Saudi SurgicalJournal 5:77-81[5] Karak PK, Millmond SH, Neumann D, Yamase HT, Ramsby G (1998) Omental infarction:report of three cases and review of the literature Abdom Imaging 23:96-98[6] Grattan-Smith JD, Blews DE, Brand T (2002) Omental infarction in pediatric patients:sonographic and CT findings AJR Am J Roentgenol 178:1537-1539CitationAliaksandr Anisau , Carine Petré , Karolina Kindt , Julie Desimpel , Filip Vanhoenacker 1, 2 1 1 1, 3 1,2, 31. General Hospital AZ Sint-Maarten Duffel-Mechelen, Leopoldstraat 2, B-2800 Mechelen,Belgium.2. University Ghent, Department of Medicine and Health Sciences.3. University Hospital Antwerp, University Antwerp, Department of Radiology, University HospitalAntwerp; Wilrijkstraat, 10, 2650 Antwerp, Belgium; Email:filip.vanhoenacker@telenet.be (2018,Jan. 20)  Omental infarction in the postpartum period {Online}URL: http://www.eurorad.org/case.php?id=15420

Omental infarction in the postpartum period

Anisau, AliaksandrUZGent0000901881729744803674531E319D00-F0EE-11E1-A9DE-61C894A0A6B4

Vanhoenacker, FilipGE328020010176270000-0002-7253-12013ACFE6BA-F0EE-11E1-A9DE-61C894A0A6B4

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https://biblio.ugent.be/publication/8545629/file/8545630

Omental infarction in the postpartum period

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