Case Report
Unusual cause of acute abdomen in a child – torsion of greater omentum: report of two cases
Scottish Medical Journal 2015, Vol. 60(3) e1–e4 ! The Author(s) 2015 Reprints and permissions: sagepub.co.uk/journalsPermissions.nav DOI: 10.1177/0036933015581129 scm.sagepub.com
Zenon Pogorelic´1, Josip Katic´2, Karla Gudelj2, Ivana Mrklic´3, Katarina Vilovic´3 and Zdravko Perko4
Abstract Introduction: Torsion of the omentum is twisting along its long axis and a rare cause of acute abdomen. Depending on associated conditions, it is classified as primary and secondary. It may mimic different pathologies presenting as acute abdomen, most common of them being acute appendicitis. Current choice for management of omental torsion is laparoscopic surgery. Case presentation: We present two cases of omental torsion of two boys who presented with abdominal pain, nausea and vomiting and underwent emergency laparoscopy. Conclusion: Omental torsion is very rare, and its diagnosis is usually made only after surgery. At laparoscopy, omental torsion is suspected when the appendix is normal and the symptoms and findings of torsion are present. Laparoscopy is a safe and effective approach for the diagnosis and management of omental torsion, with the advantages of reduced postoperative pain and hospital stay.
Keywords Omental torsion, greater omentum, children, acute abdomen, acute appendicitis, laparoscopy
Introduction Omental torsion is a rare cause of acute abdomen. The greater omentum torsion unrelated to any other intra-abdominal lesion was first reported by Eitel in 1899.1 Although the precise cause is unknown, predisposing and precipitating factors can be identified. Depending on associated conditions, it is classified as primary and secondary. Recent publications show an increase of omental torsion cases in the paediatric age group.2,3 The affected part of omentum is usually on the right side of the midline because it is more mobile than the left side omentum. Longer duration of the torsion can lead to omental necrosis. There is no specific clinical presentation of this condition. It mimics different pathologies presenting as acute abdomen, most commonly acute appendicitis. Ultrasound (US) and computed tomography (CT) can be useful, but the diagnosis is often made surgically. Current choice for management of omental torsion is laparoscopic surgery.4
We present two cases of omental torsion of two boys who presented with abdominal pain, nausea and vomiting and underwent emergency laparoscopy.
Case report 1 Medical history A 9-year-old boy presented to our paediatric surgery emergency department because of sudden onset of 1 Attending Physician, Department of Pediatric Surgery, Split University Hospital Centre and Split University School of Medicine, Croatia 2 Student, School of Medicine, University of Split, Croatia 3 Attending Physician, Department of Pathology, Split University Hospital Centre and Split University School of Medicine, Croatia 4 Chief Surgeon, Department of Surgery, Split University Hospital Centre and Split University School of Medicine, Croatia
Corresponding author: Zenon Pogorelic´, Department of Pediatric Surgery, Split University Hospital Centre, Spincˇic´eva 1, 21 000 Split, Croatia. Email: [email protected]
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abdominal pain, nausea and vomiting that begun two days before admission. The pain was located at whole right hemiabdomen, especially in the right iliac fossa. The patient had no past medical history.
Clinical features The patient was conscious, dehydrated, his blood pressure was 125/72 mmHg, pulse 76 beats/min and body temperature 37.6 C. On physical examination, the patient had direct and rebound tenderness on the right side, especially in right iliac fossa accompanied with abdominal distension. The white blood cell count was 12.80 109/l (normal range: 4.4–11.6 109/ l), the proportion of neutrophils in white blood cell differential count was elevated (82.7%) and C reactive protein level was 40.0 mg/l (normal range: 0–5 mg/l). All other laboratory examinations showed normal values. Abdominal US was normal, only small amount of free fluid between intestinal loops in right iliac fossa was detected.
Figure 1. Intra-operative findings: torsion of greater omentum, affected part of omentum was edematous and necrotic, twisted for 720 in counterclockwise direction.
Differential diagnosis The differential diagnosis in children includes appendicitis, Meckel’s diverticulitis, mesenteric lymphadenitis, gastroduodenitis, Crohn’s disease or torsion of epiploic appendage.
Operative findings An emergency laparoscopy was performed, which revealed vermiform, no inflamed, appendix. Small amount of bloody fluid was detected in abdominal cavity. Behind the liver, in the right upper abdomen, torsion of greater omentum was found. Affected part of omentum was twisted for 720 in counterclockwise direction, and it was edematous and necrotic (Figure 1). Typical laparoscopic appendectomy and resection of the necrotic part of greater omentum using thermal fusion technology (MiSealTM, Microline, Beverly, MA, USA) were performed.
Figure 2. Histopathologic findings: the adipose tissue was permeated with fresh blood and neutrophils with foci of necrosis and the stagnation of blood in blood vessels.
rapid recovery and was discharged from the hospital on second day after the surgery.
Case report 2 Medical history
Pathologic examination Histopathological examination revealed the adipose tissue permeated with fresh blood and neutrophils with foci of necrosis and the stagnation of blood in blood vessels (Figure 2).
A 10-year-old boy presented to our emergency department with abdominal pain and vomiting, which started a day before admission. The pain was located at the right lower quadrant. The stool was normal. The patient had no medical history.
Outcome, prognosis and follow-up The patient was treated on a paediatric surgical ward. All the postoperative time, the patient was afebrile and completely tolerated per oral diet. The patient made
Clinical features The patient was conscious, orientated, afebrile, dehydrated, his blood pressure was 120/65 mmHg and pulse
Downloaded from scm.sagepub.com at Stockholm University Library on August 10, 2015
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71 beats/min. Physical examination revealed pain located in right iliac fossa accompanied with peritoneal tenderness. Heart and lung examinations were normal. The white blood cell count was 10.40 109/l (normal range: 4.4–11.6 109/l) and C reactive protein level was 20.5 mg/l (normal range: 0–5 mg/l). All other laboratory examinations showed normal values.
Differential diagnosis The differential diagnosis in children includes appendicitis, Meckel’s diverticulitis, mesenteric lymphadenitis, gastroduodenitis, Crohn’s disease or torsion of epiploic appendage.
Operative findings An emergency laparoscopy was performed, which revealed vermiform, no inflamed, appendix. Small amount of bloody fluid was detected in ileocecal region and lesser pelvis. The blood was aspirated. In ileocoecal region great omentum was edematous, twisted for 540 in a counterclockwise direction and adhered to the lateral abdominal wall. A segmental omentectomy and appendectomy were performed using thermal fusion technology (MiSealTM, Microline, Beverly, MA, USA).
Pathologic examination Histopathological examination revealed adipose tissue with severe stagnation of blood in the blood vessels, focally permeated with erythrocytes and neutrophils.
Outcome, prognosis and follow-up The patient was treated on a paediatric surgical ward. All the postoperative time, the patient was afebrile and completely tolerated per oral diet. The patient made rapid recovery and was discharged from the hospital on third day after the surgery.
Discussion The greater omentum grows freely from the greater curvature of the stomach and forms the four-layered, fat-laden omental apron. According to previous reports, the estimated incidence of primary torsion of the greater omentum in children undergoing laparotomy for suspected appendicitis varies between 0.024% and 0.1%.5,6 The male and obese patients are at greatest risk.7 Omental torsion is classified as primary when no coexisting causative condition is identified, but it can occur in various conditions, such as omentum bifid and obesity or
secondary in association with causative condition such as a hernia, tumour or adhesion. Torsion of the greater omentum is defined as the axial twisting of the omentum around its long axis. If the twist is tight enough, or the venous obstruction is of sufficient duration, arterial inflow will become compromised, leading to infarction and necrosis. Primary omental torsion usually involves the right side of the omentum because that part of the omentum is longer and more mobile than the left side. Clinically, torsion of the omentum often mimics other more common acute abdominal conditions associated with right side abdominal pain, such as appendicitis, cholecystitis, cecal diverticulitis, appendagitis and twisted ovarian cyst.8–11 The main symptom of omental torsion is abdominal pain usually localised in the right-lower quadrant.3,9,10 Other symptoms are nausea, vomiting and low-grade fever. Physical findings are abdominal tenderness, guarding, mild rebound tenderness usually in the right-lower quadrant and sometimes a palpable abdominal mass.3,9,10 Leukocytosis is frequent finding. US and CT scanning are useful for preoperative diagnosis of omental torsion. US may reveal focal area of increased echogenicity in the omental fat.12 CT often demonstrates an omental mass with signs of inflammation. A CT scan shows either a whirling pattern of fibrous and fatty folds within the greater omentum or an inflamed fat-containing mass with concentric streaks around a vascular pedicle.13 The imaging differential diagnoses of omental torsion include mesenteric panniculitis, lipoma, liposarcoma, teratoma, angiomyolipoma, epiploic appendagitis, gossypiboma and fat-containing tumours.12 Usually, laparoscopy is a safe diagnostic and therapeutic modality.14 At laparoscopy, there may be free serosanguineous fluid in the abdominal cavity.4,9 Omental torsion is suspected when the appendix is normal, and the symptoms and findings of torsion are present.4,9 Treatment is excision of the involved portion of omentum.4,9 Laparoscopic approach is a safe and effective alternative for the management of omentum torsion.4 Conservative management has also been reported by some authors in selected patients with a preoperative diagnosis of omentum torsion based on CT findings.15 We recommend surgical management of primary omental torsion because delayed or conservative treatment may lead to several complications such as intra-abdominal abscess, sepsis and adhesion formation.
Conclusion Omental torsion is very rare, and its diagnosis is usually made only after surgery. Nowadays, laparoscopy is a safe and effective approach for the diagnosis and
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management of omental torsion, with the advantages of reduced postoperative pain and hospital stay. At laparoscopy, ‘omental torsion is suspected when the appendix is normal, and the symptoms and findings of torsion are present’.
Learning points . Torsion of the greater omentum is defined as the axial twisting of the omentum around its long axis. . Torsion of the omentum often mimics other more common acute abdominal conditions associated with right side abdominal pain. . US and CT can be useful, but the diagnosis is often made surgically. . Laparoscopy is a safe diagnostic and therapeutic modality.
Authors contributions The work presented here was carried out in collaboration between all authors. Zenon Pogorelic´ and Zdravko Perko performed operation. Ivana Mrklic´ and Katarina Vilovic´ performed pathohistological analysis and report. Ivana Mrklic´, Karla Gudelj, Josip Katic´ and Zenon Pogorelic´ defined the research theme. Josip Katic´ and Karla Gudelj performed literature review and wrote the paper. Zenon Pogorelic´, Katarina Vilovic´ and Zdravko Perko have been involved in drafting the manuscript or revising it critically for important intellectual content. Zenon Pogorelic´, Katarina Vilovic´ and Zdravko Perko have given final approval of the version to be published. All authors have contributed to, seen and approved the manuscript. Declaration of conflicting interests None declared.
Funding
References 1. Eitel GG. Rare omental torsion. NY Med Rec 1899; 55: 715. 2. Theriot JA, Sayat J, Franco S, et al. Childhood obesity: a risk factor for omental torsion. Pediatrics 2003; 112: e460. 3. Varjavandi V, Lessin M, Kooros K, et al. Omental infarction: risk factors in children. J Pediatr Surg 2003; 38: 233–235. 4. Tsironis A, Zikos N, Bali C, et al. Acute abdomen due to primary omental torsion: case report. J Emerg Med 2013; 44: e45–e48. 5. Houben CH, Powis M and Wright VM. Segmental infarction of the omentum: a difficult diagnosis. Eur J Pediatr Surg 2003; 13: 57–59. 6. Valioulis I, Tzallas D and Kallintzis N. Primary torsion of the greater omentum in children—a neglected cause of acute abdomen? Eur J Pediatr Surg 2003; 13: 341–343. 7. Le Roux F, Gennuso F, Lipsker A, et al. Omental torsion, a rare cause of acute surgical abdomen. J Visc Surg 2013; 150: 421–422. 8. Breunung N and Strauss P. A diagnostic challenge: primary omental torsion and literature review – a case report. World J Emerg Surg 2009; 4: 40. 9. Karayianakis AJ, Polychronidis A, Chatzigianni E, et al. Primary torsion of the greater omentum: report of a case. Surg Today 2002; 32: 913–915. 10. Efthimiou M, Kouritas VK, Fafoulakis F, et al. Primary torsion of the greater omentum: report of two cases. Surg Today 2009; 39: 64–67. 11. Pogorelic´ Z, Stipic´ R, Druzijanic´ N, et al. Torsion of epiploic appendage mimic acute appendicitis. Coll Antropol 2011; 35: 1299–1302. 12. Stella DL and Schelleman TG. Segmental infarction of the omentum secondary to torsion: ultrasound and computed tomography diagnosis. Aust Radiol 2000; 44: 212–215. 13. Al Tokhais TI, Bokhari AA and Noureldin OH. Primary omental torsion: a rare cause of acute abdomen. Saudi J Gastroenterol 2007; 13: 144–146. 14. Peirce C, Martin ST and Hyland JM. The use of minimally invasive surgery in the management of idiopathic omental torsion: the diagnostic and therapeutic role of laparoscopy. Int J Surg Case Rep 2011; 2: 125–127. 15. Kim J, Kim Y, Cho OK, et al. Omental torsion: CT features. Abdom Imaging 2004; 29: 502–504.
This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.
Downloaded from scm.sagepub.com at Stockholm University Library on August 10, 2015
Unusual cause of acute abdomen in a child – torsion of greater omentum: report of two cases
Scottish Medical Journal 2015, Vol. 60(3) e1–e4 ! The Author(s) 2015 Reprints and permissions: sagepub.co.uk/journalsPermissions.nav DOI: 10.1177/0036933015581129 scm.sagepub.com
Zenon Pogorelic´1, Josip Katic´2, Karla Gudelj2, Ivana Mrklic´3, Katarina Vilovic´3 and Zdravko Perko4
Abstract Introduction: Torsion of the omentum is twisting along its long axis and a rare cause of acute abdomen. Depending on associated conditions, it is classified as primary and secondary. It may mimic different pathologies presenting as acute abdomen, most common of them being acute appendicitis. Current choice for management of omental torsion is laparoscopic surgery. Case presentation: We present two cases of omental torsion of two boys who presented with abdominal pain, nausea and vomiting and underwent emergency laparoscopy. Conclusion: Omental torsion is very rare, and its diagnosis is usually made only after surgery. At laparoscopy, omental torsion is suspected when the appendix is normal and the symptoms and findings of torsion are present. Laparoscopy is a safe and effective approach for the diagnosis and management of omental torsion, with the advantages of reduced postoperative pain and hospital stay.
Keywords Omental torsion, greater omentum, children, acute abdomen, acute appendicitis, laparoscopy
Introduction Omental torsion is a rare cause of acute abdomen. The greater omentum torsion unrelated to any other intra-abdominal lesion was first reported by Eitel in 1899.1 Although the precise cause is unknown, predisposing and precipitating factors can be identified. Depending on associated conditions, it is classified as primary and secondary. Recent publications show an increase of omental torsion cases in the paediatric age group.2,3 The affected part of omentum is usually on the right side of the midline because it is more mobile than the left side omentum. Longer duration of the torsion can lead to omental necrosis. There is no specific clinical presentation of this condition. It mimics different pathologies presenting as acute abdomen, most commonly acute appendicitis. Ultrasound (US) and computed tomography (CT) can be useful, but the diagnosis is often made surgically. Current choice for management of omental torsion is laparoscopic surgery.4
We present two cases of omental torsion of two boys who presented with abdominal pain, nausea and vomiting and underwent emergency laparoscopy.
Case report 1 Medical history A 9-year-old boy presented to our paediatric surgery emergency department because of sudden onset of 1 Attending Physician, Department of Pediatric Surgery, Split University Hospital Centre and Split University School of Medicine, Croatia 2 Student, School of Medicine, University of Split, Croatia 3 Attending Physician, Department of Pathology, Split University Hospital Centre and Split University School of Medicine, Croatia 4 Chief Surgeon, Department of Surgery, Split University Hospital Centre and Split University School of Medicine, Croatia
Corresponding author: Zenon Pogorelic´, Department of Pediatric Surgery, Split University Hospital Centre, Spincˇic´eva 1, 21 000 Split, Croatia. Email: [email protected]
Downloaded from scm.sagepub.com at Stockholm University Library on August 10, 2015
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abdominal pain, nausea and vomiting that begun two days before admission. The pain was located at whole right hemiabdomen, especially in the right iliac fossa. The patient had no past medical history.
Clinical features The patient was conscious, dehydrated, his blood pressure was 125/72 mmHg, pulse 76 beats/min and body temperature 37.6 C. On physical examination, the patient had direct and rebound tenderness on the right side, especially in right iliac fossa accompanied with abdominal distension. The white blood cell count was 12.80 109/l (normal range: 4.4–11.6 109/ l), the proportion of neutrophils in white blood cell differential count was elevated (82.7%) and C reactive protein level was 40.0 mg/l (normal range: 0–5 mg/l). All other laboratory examinations showed normal values. Abdominal US was normal, only small amount of free fluid between intestinal loops in right iliac fossa was detected.
Figure 1. Intra-operative findings: torsion of greater omentum, affected part of omentum was edematous and necrotic, twisted for 720 in counterclockwise direction.
Differential diagnosis The differential diagnosis in children includes appendicitis, Meckel’s diverticulitis, mesenteric lymphadenitis, gastroduodenitis, Crohn’s disease or torsion of epiploic appendage.
Operative findings An emergency laparoscopy was performed, which revealed vermiform, no inflamed, appendix. Small amount of bloody fluid was detected in abdominal cavity. Behind the liver, in the right upper abdomen, torsion of greater omentum was found. Affected part of omentum was twisted for 720 in counterclockwise direction, and it was edematous and necrotic (Figure 1). Typical laparoscopic appendectomy and resection of the necrotic part of greater omentum using thermal fusion technology (MiSealTM, Microline, Beverly, MA, USA) were performed.
Figure 2. Histopathologic findings: the adipose tissue was permeated with fresh blood and neutrophils with foci of necrosis and the stagnation of blood in blood vessels.
rapid recovery and was discharged from the hospital on second day after the surgery.
Case report 2 Medical history
Pathologic examination Histopathological examination revealed the adipose tissue permeated with fresh blood and neutrophils with foci of necrosis and the stagnation of blood in blood vessels (Figure 2).
A 10-year-old boy presented to our emergency department with abdominal pain and vomiting, which started a day before admission. The pain was located at the right lower quadrant. The stool was normal. The patient had no medical history.
Outcome, prognosis and follow-up The patient was treated on a paediatric surgical ward. All the postoperative time, the patient was afebrile and completely tolerated per oral diet. The patient made
Clinical features The patient was conscious, orientated, afebrile, dehydrated, his blood pressure was 120/65 mmHg and pulse
Downloaded from scm.sagepub.com at Stockholm University Library on August 10, 2015
Pogorelic´ et al.
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71 beats/min. Physical examination revealed pain located in right iliac fossa accompanied with peritoneal tenderness. Heart and lung examinations were normal. The white blood cell count was 10.40 109/l (normal range: 4.4–11.6 109/l) and C reactive protein level was 20.5 mg/l (normal range: 0–5 mg/l). All other laboratory examinations showed normal values.
Differential diagnosis The differential diagnosis in children includes appendicitis, Meckel’s diverticulitis, mesenteric lymphadenitis, gastroduodenitis, Crohn’s disease or torsion of epiploic appendage.
Operative findings An emergency laparoscopy was performed, which revealed vermiform, no inflamed, appendix. Small amount of bloody fluid was detected in ileocecal region and lesser pelvis. The blood was aspirated. In ileocoecal region great omentum was edematous, twisted for 540 in a counterclockwise direction and adhered to the lateral abdominal wall. A segmental omentectomy and appendectomy were performed using thermal fusion technology (MiSealTM, Microline, Beverly, MA, USA).
Pathologic examination Histopathological examination revealed adipose tissue with severe stagnation of blood in the blood vessels, focally permeated with erythrocytes and neutrophils.
Outcome, prognosis and follow-up The patient was treated on a paediatric surgical ward. All the postoperative time, the patient was afebrile and completely tolerated per oral diet. The patient made rapid recovery and was discharged from the hospital on third day after the surgery.
Discussion The greater omentum grows freely from the greater curvature of the stomach and forms the four-layered, fat-laden omental apron. According to previous reports, the estimated incidence of primary torsion of the greater omentum in children undergoing laparotomy for suspected appendicitis varies between 0.024% and 0.1%.5,6 The male and obese patients are at greatest risk.7 Omental torsion is classified as primary when no coexisting causative condition is identified, but it can occur in various conditions, such as omentum bifid and obesity or
secondary in association with causative condition such as a hernia, tumour or adhesion. Torsion of the greater omentum is defined as the axial twisting of the omentum around its long axis. If the twist is tight enough, or the venous obstruction is of sufficient duration, arterial inflow will become compromised, leading to infarction and necrosis. Primary omental torsion usually involves the right side of the omentum because that part of the omentum is longer and more mobile than the left side. Clinically, torsion of the omentum often mimics other more common acute abdominal conditions associated with right side abdominal pain, such as appendicitis, cholecystitis, cecal diverticulitis, appendagitis and twisted ovarian cyst.8–11 The main symptom of omental torsion is abdominal pain usually localised in the right-lower quadrant.3,9,10 Other symptoms are nausea, vomiting and low-grade fever. Physical findings are abdominal tenderness, guarding, mild rebound tenderness usually in the right-lower quadrant and sometimes a palpable abdominal mass.3,9,10 Leukocytosis is frequent finding. US and CT scanning are useful for preoperative diagnosis of omental torsion. US may reveal focal area of increased echogenicity in the omental fat.12 CT often demonstrates an omental mass with signs of inflammation. A CT scan shows either a whirling pattern of fibrous and fatty folds within the greater omentum or an inflamed fat-containing mass with concentric streaks around a vascular pedicle.13 The imaging differential diagnoses of omental torsion include mesenteric panniculitis, lipoma, liposarcoma, teratoma, angiomyolipoma, epiploic appendagitis, gossypiboma and fat-containing tumours.12 Usually, laparoscopy is a safe diagnostic and therapeutic modality.14 At laparoscopy, there may be free serosanguineous fluid in the abdominal cavity.4,9 Omental torsion is suspected when the appendix is normal, and the symptoms and findings of torsion are present.4,9 Treatment is excision of the involved portion of omentum.4,9 Laparoscopic approach is a safe and effective alternative for the management of omentum torsion.4 Conservative management has also been reported by some authors in selected patients with a preoperative diagnosis of omentum torsion based on CT findings.15 We recommend surgical management of primary omental torsion because delayed or conservative treatment may lead to several complications such as intra-abdominal abscess, sepsis and adhesion formation.
Conclusion Omental torsion is very rare, and its diagnosis is usually made only after surgery. Nowadays, laparoscopy is a safe and effective approach for the diagnosis and
Downloaded from scm.sagepub.com at Stockholm University Library on August 10, 2015
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management of omental torsion, with the advantages of reduced postoperative pain and hospital stay. At laparoscopy, ‘omental torsion is suspected when the appendix is normal, and the symptoms and findings of torsion are present’.
Learning points . Torsion of the greater omentum is defined as the axial twisting of the omentum around its long axis. . Torsion of the omentum often mimics other more common acute abdominal conditions associated with right side abdominal pain. . US and CT can be useful, but the diagnosis is often made surgically. . Laparoscopy is a safe diagnostic and therapeutic modality.
Authors contributions The work presented here was carried out in collaboration between all authors. Zenon Pogorelic´ and Zdravko Perko performed operation. Ivana Mrklic´ and Katarina Vilovic´ performed pathohistological analysis and report. Ivana Mrklic´, Karla Gudelj, Josip Katic´ and Zenon Pogorelic´ defined the research theme. Josip Katic´ and Karla Gudelj performed literature review and wrote the paper. Zenon Pogorelic´, Katarina Vilovic´ and Zdravko Perko have been involved in drafting the manuscript or revising it critically for important intellectual content. Zenon Pogorelic´, Katarina Vilovic´ and Zdravko Perko have given final approval of the version to be published. All authors have contributed to, seen and approved the manuscript. Declaration of conflicting interests None declared.
Funding
References 1. Eitel GG. Rare omental torsion. NY Med Rec 1899; 55: 715. 2. Theriot JA, Sayat J, Franco S, et al. Childhood obesity: a risk factor for omental torsion. Pediatrics 2003; 112: e460. 3. Varjavandi V, Lessin M, Kooros K, et al. Omental infarction: risk factors in children. J Pediatr Surg 2003; 38: 233–235. 4. Tsironis A, Zikos N, Bali C, et al. Acute abdomen due to primary omental torsion: case report. J Emerg Med 2013; 44: e45–e48. 5. Houben CH, Powis M and Wright VM. Segmental infarction of the omentum: a difficult diagnosis. Eur J Pediatr Surg 2003; 13: 57–59. 6. Valioulis I, Tzallas D and Kallintzis N. Primary torsion of the greater omentum in children—a neglected cause of acute abdomen? Eur J Pediatr Surg 2003; 13: 341–343. 7. Le Roux F, Gennuso F, Lipsker A, et al. Omental torsion, a rare cause of acute surgical abdomen. J Visc Surg 2013; 150: 421–422. 8. Breunung N and Strauss P. A diagnostic challenge: primary omental torsion and literature review – a case report. World J Emerg Surg 2009; 4: 40. 9. Karayianakis AJ, Polychronidis A, Chatzigianni E, et al. Primary torsion of the greater omentum: report of a case. Surg Today 2002; 32: 913–915. 10. Efthimiou M, Kouritas VK, Fafoulakis F, et al. Primary torsion of the greater omentum: report of two cases. Surg Today 2009; 39: 64–67. 11. Pogorelic´ Z, Stipic´ R, Druzijanic´ N, et al. Torsion of epiploic appendage mimic acute appendicitis. Coll Antropol 2011; 35: 1299–1302. 12. Stella DL and Schelleman TG. Segmental infarction of the omentum secondary to torsion: ultrasound and computed tomography diagnosis. Aust Radiol 2000; 44: 212–215. 13. Al Tokhais TI, Bokhari AA and Noureldin OH. Primary omental torsion: a rare cause of acute abdomen. Saudi J Gastroenterol 2007; 13: 144–146. 14. Peirce C, Martin ST and Hyland JM. The use of minimally invasive surgery in the management of idiopathic omental torsion: the diagnostic and therapeutic role of laparoscopy. Int J Surg Case Rep 2011; 2: 125–127. 15. Kim J, Kim Y, Cho OK, et al. Omental torsion: CT features. Abdom Imaging 2004; 29: 502–504.
This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.
Downloaded from scm.sagepub.com at Stockholm University Library on August 10, 2015
