A diagnostic challenge: primary omental torsion and literature review - a case report

The four layered fatty sheet of peritoneum is known as omentum and suspends from the greater gastric curvature to surrounding organs with attachments to the diaphragm [1]. Omental torsion is caused by twisting of sections of the omentum along its long axis resulting in vascular compromise. First described by Eitel in 1899 it is a rare cause of the acute surgical abdomen [2,3]. Fewer than 250 cases have been described in the literature so far. Omental torsion is rarely diagnosed preoperatively and may lead to spontaneous clinical deterioration of the patient [2,4]. Laparoscopy is the current choice for diagnosis and management [5].A 44 year old female patient presented to the Emergency Department complaining of generalised abdominal pain for three days, localising to the right iliac fossa. Accompanying symptoms were nausea and constipation, but bowels had opened on day of presentation. No urinary symptoms, past medical history of note or regular medication were present.On examination the patient was haemodynamically stable and apyrexial. The abdomen was soft, not distended, with localised tenderness in the right iliac fossa without peritonitis. Apart from a mild leukocytosis (11.2 × 109/L), the blood count and serum biochemistry were normal on first presentation.She was initially discharged home, but returned the following day with unresolving symptoms and was referred to the surgical team.Abdominal ultrasound was normal and no appendix mass identified. After two days of observation and non resolving symptoms the patient underwent diagnostic laparoscopy, with a suspicion of appendicitis.On laparoscopy a small amount of blood stained fluid and an inflammatory mass consisting of a section of infarcted omentum and adherent thickened small bowel were identified. Appendix, gallbladder and pelvis showed no abnormality. The procedure was extended to a mini-laparotomy. The inflammatory mass was dissected and identified as an omental torsion with three twists (Figure 1). The