Re: Omental infarction: a case of a whole omental infarct

Abstract

Re: Omental infarction: a case of a whole omental infarctWe note with interest the recent publication of a case report by Ong et al. 1 describing a 27-year-old man with an omental infarction. We have recently published a series of 30 cases of children with omental infarction, where the diagnosis was made on ultrasound, and hope to add to this described case. To our knowledge, ours is the largest case series of omental infarction in children in the literature. 2 We identified 30 children who presented to our hospital over a 10-year period, ranging from 3 to 17 years of age. Obesity appears to be a critical factor in the pathogenesis, with 36.6% of patients having a weight-for-age Z-score of greater than 2, 83.3% were heavier than the mean for their age, and only one patient (3.3%) was significantly underweight.Gastrointestinal symptoms were common in our series, in contrast to previous literature, with 70% of patients describing anorexia, 53.3% suffering nausea, 26.6% having at least one vomit and 23.3% with at least one episode of diarrhoea. Pain was most often right sided (86%). Only 36.6% of our patients had a temperature greater than 37.5 C, which is also in contrast to the 'typical' presentation described by Ong et al. and other series. Laboratory markers were not helpful, with 56.7 and 36.6% of patients having an elevated CRP and white cell count, respectively.Omental infarction was diagnosed in every case on ultrasound, either in the initial scan or in a repeat ultrasound at least 24 h later. In 18 of the 30 cases, an appendix was identified, ruling out appendicitis. Only one patient underwent a CT scan to aid in confirming the diagnosis.In our series, 17 cases were managed operatively, and 13 managed with analgesia alone. The conservatively managed group had a shorter length of stay than the operative group, but four patients were readmitted for further analgesia. There were no serious complications in either group. Most significantly, we did not identify any cases of incorrect diagnosis of omental infarction on ultrasound, or missed appendicitis. If the diagnosis is made with confidence, it is safe to manage non-operatively. Although CT is considered the gold standard for diagnosis, we believe that ultrasound is a useful tool in the diagnosis of omental infarction in children, thereby sparing patients from unnecessary surgery or ionizing radiation.

Omental infarction in an overweight child: conservative treatment is a safe approach

“…For preoperative diagnosis of OI, a CT scan showing a well-circumscribed, fatty, inflammatory mass with normal neighbouring viscera has been regarded as the gold standard. Ultrasound (US) has a high specificity for the diagnosis of OI; however, the literature indicates a sensitivity between 60% and 80% 11. Early detection of OI by abdominal US seems to minimise the amount of unwarranted investigations (such as CT scans), shorten hospital stays and avoid unwarranted surgical operations 4…”

“…Accurate diagnosis of OI by CT scanning has reduced the need for diagnostic laparoscopy, and the great majority of patients have recovered without surgery 7 13. Although CT is the diagnostic gold standard, early use of USG is a good approach for identifying OI in children, saving patients from needless surgery or ionising radiation exposure 11…”