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Omental Infarction in Pediatric Patients: Sonographic and CT Findings

¹ Department of Radiology, Children's Healthcare of Atlanta at Scottish Rite, 1001 Johnson Ferry Rd., Atlanta, GA 30342.
² Department of Surgery, Children's Healthcare of Atlanta at Scottish Rite, Atlanta, GA 30342.

Received August 21, 2001; accepted after revision December 6, 2001.

 
Address correspondence to J. D. Grattan-Smith.

Abstract

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OBJECTIVE. Children with omental infarction typically present with abdominal pain and are diagnosed clinically as having acute appendicitis. Our purpose was to perform a retrospective review of the imaging findings in nine children with omental infarction as an aid to radiologists in distinguishing this entity from acute appendicitis.

CONCLUSION. In pediatric patients with omental infarction, both CT and sonography show a heterogeneous mass characteristically situated between the anterior abdominal wall and the colon. It is important for radiologists to recognize the characteristic imaging findings seen with omental infarction.

Introduction

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Omental infarction is a rare cause of acute abdominal pain in children; more than 85% of reported cases occur in adults [1,2,3,4,5,6]. Clinical features are often nonspecific, and the presumptive diagnosis in children is most often appendictis. The cause is unknown. Recently, several authors have described characteristic imaging findings of omental infarction in adults on both sonography and CT [1, 4, 5, 7, 8]. In 4 years, nine children at our institution underwent imaging studies before diagnosis of omental infarction.

Materials and Methods

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We searched medical records at our institution for the period of January 1997—December 2000 for patients with the discharge diagnosis of omental infarction and identified 13 children with this final diagnosis. We performed a retrospective review of the pediatric patients' clinical presentation, diagnostic imaging results, and surgical and pathologic findings. Four of the 13 children underwent surgery without imaging studies because the surgeon was confident of the clinical diagnosis of acute appendicitis. Preoperative imaging studies were performed in the other nine children, who were included in our study population.

All nine patients (five boys and four girls; age range, 3-11 years; mean age, 8 years) presented with right-sided abdominal pain, which localized to the right lower quadrant in six patients. Their WBC ranged from 3.3 to 14 (mean value, 9.7), and C-reactive protein was present with values ranging from 1.6 to 12.4 (mean value, 5.2) Two children underwent sonographic evaluation only, four were evaluated with sonography and CT, and three underwent CT only.

Results

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No abnormal findings were detected in the two children who were evaluated using sonography alone. Because of the clinical concern for appendicitis, laparoscopy was performed on these patients, and right-sided omental infarction was diagnosed in both. Four children underwent CT after sonography: one because the normal findings on sonography did not fit the clinical setting and three because the sonographic findings were abnormal. In those three children, an echogenic and poorly defined mass was identified in the right side of the abdomen corresponding to the area of maximal tenderness (Fig. 1A). CT revealed a heterogeneous fatty mass anterior to the ascending or the transverse colon immediately beneath the anterior abdominal wall (Fig. 1B). In the three children who were evaluated with CT alone, similar heterogeneous masses located just beneath the abdominal wall were identified anterior to the ascending or transverse colons (Fig. 2). In five of the seven children in whom abnormal findings were revealed, the preoperative diagnosis of omental infarction was made on CT. In the other two patients, findings indicating omental infarction were not recognized on initial interpretation but were evident on review. Eight of the nine patients in our study underwent laparoscopic surgery for removal of the infarcted omentum, and recovery was uneventful. One patient was treated conservatively.

View larger version (163K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 1A. —8-year-old boy with right lower quadrant pain and tenderness. Sonogram obtained over point of maximal tenderness using 7-MHz linear transducer shows poorly defined hyperechoic mass immediately below anterior abdominal wall.

View larger version (120K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 1B. —8-year-old boy with right lower quadrant pain and tenderness. Axial CT scan performed immediately after A shows heterogeneous, predominately low-attenuation mass (arrows) just beneath anterior abdominal wall. Mass, which is anterior to transverse colon, is triangular.

View larger version (117K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 2. —7-year-old boy with right-sided abdominal pain. Axial CT scan through right lower quadrant shows large triangular mass (arrows) between ascending colon and anterior abdominal wall. Mass is predominantly fatty, interspersed with higher attenuating linear densities. Inflammatory changes can be seen in adjacent colon. CT appearance is characteristic for omental infarction.

Discussion

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Children with omental infarction typically present with sudden onset of right-sided abdominal pain and tenderness. In most patients, the tenderness is localized. The presumed diagnosis in children is usually appendicitis. Traditionally, omental infarction has been labeled as being with or without torsion. This classification is clinically irrelevant because treatment is identical in all cases [5, 9]. Theories about the causes of omental infarction include anomalous arterial supply to the omentum, kinking of veins associated with increased intraabdominal pressure, or vascular congestion after large meals [5]. Pathologic findings include congestion, hemorrhage, fat necrosis, and varying degrees of inflammatory cell infiltration. In most patients segmental omental infarction is a self-limited, benign condition that may resolve spontaneously. The inflammatory response resolves with retraction and fibrosis leading to either complete healing or autoamputation [5, 7, 10]. Reported complications include adhesions with bowel obstruction and abscess formation [10, 11].

The imaging features seen in our patients were characteristic and identical to those described in adults [1, 5, 7]. Omental infarction is typically triangular and involves the inferior aspect of the right side of the omentum. It is characteristically situated between the anterior abdominal wall and the transverse or ascending colon, corresponding in location to the greater omentum. Both CT and sonography show an ovoid or cakelike soft-tissue mass. The infarcted omental fat is hyperechoic on sonography and shows mixed attenuation on CT. Schlesinger et al. [1] found that sonography was specific but not sensitive in the diagnosis of omental infarction. These researchers correctly diagnosed omental infarction preoperatively using sonography in four of nine children. We had similar experience: three of the six children evaluated using sonography had normal findings, even when reviewed retrospectively. In the three children whose sonographic findings were abnormal, the imaging findings were characteristic of omental infarction. The imaging findings for this entity can be subtle on sonography, and recognition of the abnormality is operator-dependent. CT offers a distinct advantage over sonography in the evaluation of omental infarction because the mass is reliably identified in the characteristic location between the anterior abdominal wall and the colon.

Although some surgeons advocate conservative treatment, many believe that laparoscopic excision is the treatment of choice. After the infarcted omentum is removed, the child's clinical symptoms resolve rapidly, and the possibility of abscess formation or other complications, such as bowel obstruction caused by adhesions, is minimized. Recovery after laparoscopic omentectomy was rapid and uneventful in all our patients.

It is not possible to distinguish omental infarction from appendicitis clinically. Because CT is being used more frequently in the investigation of children with acute abdominal pain, knowledge of the characteristic imaging features of omental infarction is important in making the diagnosis preoperatively and in distinguishing omental infarction from acute appendicitis.

References

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1. Schlesinger AE, Dorfman SR, Braverman RM. Sonographic appearance of omental infarction in children. Pediatr Radiol 1999;29:598 -601[Medline]
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