Primary idiopathic segmental infarction and torsion of greater omentum: Report of two cases
ROBERT E. FOX, JR., D o Wagoner, Oklahoma
the first report of primary torsion of the omentum.2 Primary idiopathic segmental torsion The first description of omental infarction was by and isolated infarction of the greater Johnson in 1932.1 omentum is a rare clinical entity A myriad of terms are used to describe this clini- which is frequently misdiagnosed. cal entity: acute segmental infarction, omental in- The clinical manifestations are farction, omental segmental infarction, spontane- varied, and diagnosis is usually made ous infarction of the greater omentum, hemor- at laparotomy. However, with rhagic infarction of the greater omentum, throm- increased awareness, the correct bosis of the omentum, omental volvulus, and acute preoperative diagnosis might be epiploitis. However, the concensus in the literature made. The presence of lower right indicates the correct term is "primary idiopathic quadrant pain, anorexia, segmental infarction of greater omentum." leukocytosis, and a low-grade fever Anton proposed the following classification: should alert one to the possibility of A. Primary (idiopathic, cryptogenic, pure intra- greater omental infarction. If there is abdominal) a negative exploratory celiotomy and B. Secondary serosanguineous fluid, the greater 1. Hernia (external, in sac) omentum should always be explored 2. Abdominal for a possible torsion and/or a. Intrinsic (cysts and tumors) infarction prior to closing the b. Extrinsic (associated with pathologic abdomen. findings of abdominal and pelvic organs and peritoneum) The next classification was published by Leitner4 in 1952 as follows: A. Omental infarction (with or without gangrene) due to torsion. Primary idiopathic segmental torsion and isolated 1. Primary (idiopathic) infarction of the greater omentum is a rare occur- 2. Secondary rence of an acute surgical abdomen which is fre- B. Omental infarction (with or without gangrene) quently misdiagnosed as acute appendicitis, acute due to thrombosis. cholecystitis, or perforated viscus. It usually is not 1. Idiopathic (spontaneous) infarction. diagnosed until laparotomy. Fortunately, most 2. Associated with vascular disease. cases present with such persistent abdominal 3. Due to external trauma. symptoms that exploratory laparotomy is per- Several cases of omental infarction have been formed. However, one should be suspicious of a reported in the past decade, bringing the total to a "negative" abdomen and explore the "abdominal probable 190 cases, as reflected by a brief review of policemen," that universal metaphor of the greater the English literature. Although it appears to be a omentuml expressed by Rutherford Morrison in rare disease by a number of reports, it is probably teaching his classes. much more common than the literature suggests, Pierre de Marchette is credited with the publica- and is not diagnosed or reported by surgeons be- tion of the first report in 1851 of torsion of the cause of its benign nature. omentum as a separate clinical entity. 2 His report Several classifications have been presented in and others that followed in the literature were of a the literature and two are noteworthy. The first is secondary type of torsion related to preexisting by Anton and associates in 1946, who published an hernias. In 1896 Bush described hemorrhage of the excellent review in which they discussed embryol- greater omentum.3 Eitel in 1899 is credited with ogy, anatomy, physiology, and pathology of the