Omental Torsion Management

Introduction

Omental torsion is a medical emergency that requires prompt diagnosis and management. An uncommon reason for sudden abdominal pain is the larger omentum being torn. There are primary or secondary types of omental torsion. Many pre-existing conditions are responsible for causing secondary omental torsion. Other causes include tumors, cysts, internal or external herniation, intra-abdominal inflammation, and post-surgical wounds or scarring.

Males are more likely to have this disorder. It mimics acute appendicitis clinically. Therefore it is a potential differential diagnosis for acute abdomen. Although explorative laparotomy is the preferred definitive and therapeutic treatment, laparoscopy can help with diagnosis and management. Nevertheless, omentectomy lowers the inflammation of the belly, making the disease not life-threatening. This article will discuss the management of omental torsion.

What Is Omentum Torsion?

Omental torsion was initially described by Eitel in 1899. Omentum torsion is an unusual cause of increased stomach pain. Omental torsion is a rare condition that occurs when a portion of the omentum, a fold of tissue in the abdomen, twists on itself, leading to a restriction in blood flow and potential damage to the affected tissue. The clinical diagnosis of torsion is very challenging because it mimics acute appendicitis in almost all cases. Omental torsion is rarely detected before surgery.

There are two types of omental torsion:

• Primary Omental Torsion - Primary omental torsion (POT) occurs due to the fold of the abdomen (omentum) getting twisted in the absence of other abdominal diseases. The primary omental torsion generally affects the age group of 30 to 50 years with male predominance but can occur in anyone. However, few cases have been reported in adults and children. Primary omental torsion can mimic a variety of other acute abdominal conditions, such as cholecystitis, acute diverticulitis, and acute appendicitis. The primary omental torsion is caused due to changes in the structure of the abdomen and abnormal blood supply.

• Secondary Omental Torsion - Secondary omental torsion (SOT) is mostly associated with predisposing factors such as pre-existing abdominal disease. Secondary omental torsion is more common than primary omental torsion. It is associated with pre-existing abdominal diseases such as cysts, tumors, intra-abdominal inflammations, surgical wounds or scarring, and hernia. Most cases of secondary omental torsion occur with hernias. Other causes responsible for secondary omental torsion are weight lifting, abdominal trauma, and post-surgical wounds.

What Are the Causes of Omental Torsion?

Omental Torsion is the common cause of acute abdomen pain. The exact cause of omental torsion has not been established.

The following are the predisposing factors responsible for omental torsion:

• Hernia (a condition when an organ pushes through a weak spot in the surrounding area of the abdomen).

• Inflammation of the abdominal cavity.

• Appendicitis (inflammation of the appendix).

• Cholecystitis (inflammation of the gallbladder).

• Diverticulitis (inflammation of the colon).

• Malformation in the structure of omentum.

• Malformation in the blood supply of the omentum.

• Cysts (an abnormal sac filled with fluid) of the abdomen.

• Tumors (mass of cancerous cells) of the abdomen.

• Lifting weights.

• Coughing.

• Forceful vomiting.

• Hard labor.

• Ingestion of heavy meals.

• Abdominal trauma.

• Obesity (excess fat deposition).

• Swelling of the abdomen.

• Post-surgical wounds of hernias.

What Are the Symptoms of Omental Torsion?

Omental torsion is an uncommon disease. Patients typically have right abdominal pain that is similar to appendicitis when they first report, but they do not have the other associated gastrointestinal symptoms of nausea, vomiting, or anorexia.

The following are the symptoms of omental torsion:

• Severe pain in the right abdomen, which is sudden in onset.

• Nausea and vomiting.

• Low-grade fever.

• Tenderness in the abdomen.

• Swelling of the abdomen.

How to Manage Omental Torsion?

The treatment of omental torsion generally involves a combination of medical and surgical approaches. Initially, patients may receive pain management, anti-inflammatory medication, and intravenous fluids. However, surgical intervention is often required to resolve the torsion and prevent further complications.

The following are the treatment options for omental torsion:

• Medical Management: Initial medical management of omental torsion aims to control pain and inflammation and restore fluid and electrolyte balance. This can be achieved through the administration of analgesics and anti-inflammatory drugs, as well as intravenous fluids. Antibiotics may also be prescribed to prevent infection. However, medical management alone is usually insufficient to resolve the torsion, and surgical intervention is usually required.

• Surgical Management: The definitive treatment for omental torsion is surgical intervention. The surgical management of omental torsion can be performed through either an open or laparoscopic approach. The choice of approach depends on the surgeon's preference, the extent and severity of the torsion, and the patient's overall condition. Laparoscopic surgery is the preferred approach as it is minimally invasive, requires a shorter recovery time, and is associated with fewer complications. During laparoscopic surgery, the surgeon creates several small incisions in the abdomen and inserts a laparoscope, a thin tube with a camera, and a light source, to visualize the affected area. The surgeon then untwists the affected portion of the omentum and removes any damaged or necrotic tissue. In some cases, the surgeon may also remove a portion of the omentum to prevent future torsion. Open surgery may be necessary in cases where laparoscopic surgery is not feasible or safe or when there is extensive damage to the omentum. During open surgery, the surgeon makes a larger incision in the abdomen and directly visualizes and manipulates the affected area.

• Post-Operative Care: After surgical management of omental torsion, patients may require a short hospital stay for monitoring and recovery. Pain management, antibiotics, and intravenous fluids may be necessary during this time. Patients may be advised to limit physical activity and avoid heavy lifting for a few weeks. Follow-up appointments with the surgeon may be necessary to monitor the patient's recovery and ensure that there are no complications.

Conclusion

Omental torsion is a rare but serious medical condition that requires prompt diagnosis and management. Surgical intervention is often necessary to resolve the torsion and prevent further complications. Patients who experience a sudden onset of abdominal pain, especially in the lower abdomen, should seek medical attention immediately. Early diagnosis and management can lead to a better prognosis and a faster recovery.