Unusual cause of right iliac fossa pain: extra‐peritoneal omentum with torsion

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Excerpt

A 32‐year‐old otherwise healthy man presented to the Emergency Department with right iliac fossa (RIF) pain. The pain was non‐migratory, dull and constant and was associated with two loose bowel motions. Upon examination, the patient was afebrile, tachycardic with localized peritonism in the RIF. Blood and urine pathology was unremarkable apart from a mildly elevated white cell count (10.9 × 109/L).
Previous medical history included similar episodes over the preceding years, which were investigated with gastroscopy, colonoscopy, computed tomography and ultrasound scans of the abdomen and pelvis and did not show any abnormality.
The patient was admitted under the Acute Surgical Unit for serial examination resulting in diagnostic laparoscopy in less than 24 h. The operative findings were a necrotic‐appearing fat lobule incorporated in the pre‐peritoneal plane corresponding to McBurney's point. There was an associated omental band adhesion as seen in Figures 1 and 2; this was resected along with a macroscopically normal appearing appendix. Microscopic histopathologies of the resected specimens were reported as a 50 mm × 35 mm × 15 mm omental tissue with congestion and peritonitis, in keeping with torsion under the serosa and a non‐inflamed appendix.
The patient recovered well in the post‐operative period with resolution of the original symptoms and returned home the following day. At review a month following surgery, the patient confirmed long‐term resolution of the symptoms and no further episodes of abdominal pain.
RIF pain is among the most common presentations to the Emergency Department requiring surgical assessment and management. A systematic approach to the differential diagnosis for this presentation, varying for each of the sexes, aids in the timely and accurate management of this condition. Patients with negative investigation and ongoing pain may ultimately require diagnostic laparoscopy, usually revealing the less common pathologies associated with RIF pain.1
Intra‐abdominal adhesions are a recognized and common cause of abdominal pain.2 It has been reported that up to 28% of adhesions are spontaneous, having no prior exposure to abdominal surgery.3 Omental torsion is rare, with less than 400 case reports. They are usually present due to an underlying abnormality such as a focus of infection, inflammation or hernia. Primary omental torsion without an underlying cause is even less common.4 The combination of omental torsion in a pre‐peritoneal plane with no previous surgery or clear predisposing factors is an unusual and as yet unreported phenomenon. Diagnostic laparoscopy and laparoscopic intervention is the management of choice for patients with RIF pain and uncertain clinical concern for acute appendicitis. This is even more pertinent when the pathological cause for the presentation has not been delineated by modern medical imaging. This approach will ultimately identify numerous rare pathological causes for RIF pain that mimic acute appendicitis, yet can still be surgically managed. This is the first report where the combination of omental torsion and necrosis in a pre‐peritoneal plane and associated band adhesion has mimicked acute appendicitis, a rare pathology that has been successfully managed with laparoscopy.
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