Carraro, Michelle N, DO

Jacoby, Jeanne L, MD

Niehaus, Matthew, DO

Reynolds, Shawn C, PA-C

Rusgo, Allison

Lehigh Valley Health Network: LVHN Scholarly Works

Lehigh Valley Health Network LVHN Scholarly Works Department of Emergency Medicine An Unusual Cause of Abdominal Pain in Pregnancy: Omental Infarction. Allison Rusgo Lehigh Valley Health Network, Allison_S.Rusgo@lvhn.org Michelle N. Carraro DO Lehigh Valley Health Network, michelle_n.carraro@lvhn.org Matthew Niehaus DO Lehigh Valley, Matthew.Niehaus@lvhn.org Shawn C. Reynolds PA-C Lehigh Valley Health Network, Shawn_C.Reynolds@lvhn.org Jeanne L. Jacoby MD Lehigh Valley Health Network, Jeanne_L.Jacoby@lvhn.org Follow this and additional works at: https://scholarlyworks.lvhn.org/emergency-medicine  Part of the Emergency Medicine Commons Published In/Presented At Rusgo, A., Carraro, M. N., Niehaus, M. T., Reynolds, S. C., & Jacoby, J. L. (2016). An unusual cause of abdominal pain in pregnancy: omental infarction. The American Journal Of Emergency Medicine, 34(6), 1184.e3-4. doi:10.1016/j.ajem.2015.11.040. This Article is brought to you for free and open access by LVHN Scholarly Works. It has been accepted for inclusion in LVHN Scholarly Works by an authorized administrator. For more information, please contact LibraryServices@lvhn.org. Case ReportAn unusual cause of abdominal pain in pregnancy:omental infarction☆,☆☆AbstractWe report a case of a 33-year-old, 28-week pregnant woman whopresented to our suburban emergency department twice with symp-toms of upper abdominal pain. She had a benign examination result,which elicited only mild tenderness and fullness in the right upperquadrant. Complete laboratory and radiographic studies, includingcomputed tomographic scan of the chest, revealed only herniation ofthe left lobe of the liver through a divarication of the abdominal wall.At laparoscopic surgery, she was noted to have omental infarction, ap-parently secondary to entrapment and vascular compromise from post-operative adhesions. Omental infarction is a rare condition, which hasbeen associated with obesity, blunt trauma, heavy lifting, occupationalvibration, and laxative use. Pregnancy has not been considered a riskfactor. Emergency physicians should be aware of this rare entity,which mimics a variety of more common causes of abdominal pain.A 33-year-old, 28-week pregnant woman with a medical history ofectopic pregnancy (treated with left salpingectomy) and endometriosispresented to our suburban emergency department complaining of rightupper quadrant abdominal pain that began several days prior. She de-scribed her symptoms as a constant “gnawing” 4/10 painwith occasion-al radiation to her left upper quadrant. The pain was alleviated bystanding and exacerbated by sitting and laying supine. The patientalso reported intermittent shortness of breath, pleuritic chest pain,and dizziness but denied any recent history of trauma, gastrointestinalillnesses, or prior similar symptoms. She had been evaluated in theemergency department for identical symptoms 2 days prior anddischarged homeafter complete blood count, basicmetabolic panel, tro-ponin, and chest x-ray were unremarkable. A chest computed tomo-graphic (CT) revealed subxiphoid ventral abdominal wall divaricationwith a portion of the left lobe of liver herniating through the defect;there was a suggestion of a small area of arteriovenous shunting in theleft lobe of the liver.The patient was in no acute distress. Initial vital signs were entirelynormal; the O2 saturation was 99%. On physical examination, her abdo-menwas gravid and soft with normal bowel sounds and a slight fullnessjust below the right costal margin. There was significant tenderness inthe right upper quadrant and epigastrum without peritoneal signs.The remainder of the physical examination was within normal limits.Laboratory studies were significant only for an increased white bloodcell count of 13.0 g/dL (9.2 g/dL on evaluation 2 days previously) anda left shift with 77% neutrophils and 6% bands.Chest x-ray, gallbladder ultrasound, and magnetic resonance imag-ing of the abdomen were all interpreted as unremarkable. Review ofthe previously performed chest CT confirmed the findings of herniationof the liver with the suggestion of arteriovenous shunting in the leftlobe (Figure).Based on the CT chest results and continued symptoms, the patientunderwent a mini exploratory laparotomy, lysis of adhesions, and par-tial omentum excision secondary to infarction. Intraoperatively, therewere no hernias identified; however, there were multiple adhesions ofthe liver to the anterior abdominal wall. In addition, a section of omen-tum was trapped within the adhesions and this infarcted portion wassuccessfully removed. The patient tolerated the procedure welland was discharged home in stable condition on postoperative day 3.She subsequently had a spontaneous vaginal delivery of a healthy boyat term.Spontaneous omental infarction in pregnancy is extremely rare andmay be difficult to diagnose. There have only been 2 prior case reports ofomental infarction in pregnancy [1,2] and 1 after cesarean section [3].Based on a 2012 review article, there have been approximately 400 re-ported cases of omental infarction, with the majority occurring in thefifth decade; it appears to be more common in males [4].Omental infarction is a mimic of more common causes of abdominalpain, including appendicitis, cholecystitis, or diverticulitis [5]. Anatomi-cally, omental infarction can occur in various locations within the ab-dominal cavity, as the omentum originates from the stomach andproximal portion of the duodenum and tracks downward to the smallintestine and anterosuperior aspect of the transverse colon [6]. Mostoften, the pathology is appreciated on the right (88.4% [38/43 reportedcases]) presumably because the omentum is longer and more mobilein this area [7] and contains altered vasculature that is less forgiving ofvenous stasis and constant twisting [8].Most cases of omental infarction are idiopathic but torsion of theomentum is a recognized cause as well. Notably, pregnancy has notbeen recognized as a precipitating factor. In most idiopathic cases, obe-sity is common and omental infarction may be related to accumulationof fat within the omentum. This abnormality increases theweight of theomentumandmayobstruct the right epiploic artery, thus increasing thelikelihood of both torsion and infarction. Factors such as overeating,blunt trauma, heavy lifting, occupational vibration, and laxative useare also associated with omental infarction, as are postoperative adhe-sions, cysts, hernias, and vascular abnormalities [8].The most efficient diagnostic study is a contrast-enhancedabdominopelvic CT scan with the pathognomonic feature described asAmerican Journal of Emergency Medicine 34 (2016) 1184.e3–1184.e4☆ The authors have no outside support information, conflicts, or financial interest to dis-close and this work has not been presented elsewhere.☆☆ A.R., J.J., S.R., M.C., and M.N. researched the case; A.R. and J.J. drafted the manuscript;and all authors contributed substantially to its revision. J.J. takes responsibility for themanuscript as a whole.0735-6757/© 2015 Elsevier Inc. All rights reserved.Contents lists available at ScienceDirectAmerican Journal of Emergency Medicinej ourna l homepage: www.e lsev ie r .com/ locate /a jemDownloaded for library services (libraryservices@lvhn.org) at Lehigh Valley Health Network from ClinicalKey.com by Elsevier on August 24, 2022. For personal use only. No other uses without permission. Copyright ©2022. Elsevier Inc. All rights reserved.an “oblong or triangular shaped fatty mass” [4] or “interspersed areawith a hyperattenuating streaky infiltration…between the gastric an-trum and anterior abdominal wall” [2]. Radiographically, this is referredto as a “whirl-sign” [6]. The criterion standard for identifying the infarc-tion is histologic examination of the affected segment of omentum.Given the rarity of this diagnosis, the standard of treatment has yetto be established. To date, there is an evolving discussion of the risksand benefits of conservative vs aggressive (surgical) management.There are several documented cases of uncomplicated omental infarc-tion that were treated successfully with fluids, analgesics, and anti-inflammatories where follow-up CT scans at 1 and 3 years after diagno-sis showed a decrease in the affected necrotic lesion [8,9]. However, notall cases of diagnosed omental infarction are candidates for conservativemanagement; patients with intractable pain, peritoneal signs, or addi-tional complicating factors, perhaps including pregnancy, may requirelaparoscopic or open surgery for definitive management.Allison Rusgo, PA-C, MPHMichelle N. Carraro, DOMatthew T. Niehaus, DOShawn C. Reynolds, MSPAS, PA-CJeanne L. Jacoby, MD⁎Department of Emergency MedicineLehigh Valley Health Network, Allentown, PA⁎Corresponding author. Emergency Medicine Research1240 South Cedar Crest Boulevard, Suite #212, Allentown, PA 18103Tel.: +1 610 402 7262x7666; fax: +1 610 402 7160E-mail address: Jeanne_L.Jacoby@lvhn.orghttp://dx.doi.org/10.1016/j.ajem.2015.11.040References[1] Leung R, Kreis DJ. Infarction of the omentum in pregnancy. South Med J 1986;79(12):1597.[2] Berlin M. Omental infarction in pregnancy. N Y State J Med 1989;89(11):634.[3] Phillips RW, Peterson CM. Infarction of the omentum after cesarean section. A case re-port. J Reprod Med 1988;33(4):382–4.[4] Park TU, Oh JH, Chang IT, Lee SJ, Kim SE, Kim CW, et al. Omental infarction: case seriesand review of the literature. J Emerg Med 2012;42(2):149–54. http://dx.doi.org/10.1016/j.jemermed.2008.07.023.[5] Litzau M, Lall MD. Idiopathic left upper quadrant omental infarction: diagnosed andmanaged conservatively in the ED. Am J Emerg Med 2015;33(5):741.e1–2. http://dx.doi.org/10.1016/j.ajem.2014.11.032.[6] BaraiKP,KnightBC.Diagnosis andmanagementof idiopathic omental infarction: a case re-port. Int J Surg Case Rep 2011;2(6):138–40. http://dx.doi.org/10.1016/j.ijscr.2011.02.014.[7] Katagiri H, Honjo K, NasuM, FujisawaM, Kojima K. Omental infarction due to omentaltorsion. Case Rep Surg 2013;2013:373810. http://dx.doi.org/10.1155/2013/373810.[8] Singh AK, Gervais DA, Lee P, Westra S, Hahn PF, Novelline RA, et al. Omental infarct:CT imaging features. Abdom Imaging 2006;31(5):549–54. http://dx.doi.org/10.1007/s00261-005-0251-6.[9] Puylaert JB. Right-sided segmental infarction of the omentum: clinical, US, and CTfindings. Radiology 1992;185(1):169–72. http://dx.doi.org/10.1148/radiology.185.1.1523302.Figure. Subxiphoid abdominal wall divaricationwith apparent liver herniation through defect.1184.e4 A. Rusgo et al. / American Journal of Emergency Medicine 34 (2016) 1184.e3–1184.e4Downloaded for library services (libraryservices@lvhn.org) at Lehigh Valley Health Network from ClinicalKey.com by Elsevier on August 24, 2022. For personal use only. No other uses without permission. Copyright ©2022. Elsevier Inc. All rights reserved.

An Unusual Cause of Abdominal Pain in Pregnancy: Omental Infarction.

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