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Letters |
Rijnland Hospital
Leiderdorp, The Netherlands
MCH Westeinde Hospital
The Hague, The Netherlands
We read with interest the article by Baldisserotto et al. [1] about color Doppler sonography in children with omental infarction. In their prospective study, patients who presented with clinical signs suggestive of appendicitis underwent surgery after preoperative sonography strongly suggested the correct diagnosis of omental infarction in most cases. This study nicely correlates sonographic features of omental infarction with surgery and pathology findings.
We are surprised, however, that these patients underwent surgery. The authors simply state that "our institution still adopts the surgical procedure that describes removal of the infarcted tissue" and provide a reference that dates from 1972. They neither mention the natural history of omental infarction nor discuss the importance of making its correct preoperative imaging diagnosis. In our view, in patients with acute abdominal symptoms, the primary aim of the radiologist is to determine the presence or absence of an abdominal condition that requires surgery or in-hospital treatment. Therefore, apart from the imaging features, a radiologist should also be familiar with the natural history of an acute abdominal disorder. If patients with omental infarction require surgery as do patients with appendicitis, a correct preoperative imaging diagnosis would have little impact on patient management.
The imaging diagnosis of omental infarction is relevant because it can prevent an unnecessary operation from being performed. Several studies, which also included some children, have indicated that omental infarction has an essentially benign natural history that allows conservative management without surgical intervention or medical treatment [2-4]. Spontaneous and complete resolution of symptoms, typically within 2 weeks, is the rule. Patients with an omental infarction can be reassured, and the disease activity can be monitored with clinical and sonographic follow-up in an outpatient setting.
In summary, we are concerned that the article by Baldisserotto et al. [1] could lead to the incorrect assumption that omental infarction requires surgery when, in fact, an operation can be avoided if diagnosed by the radiologist.
References
Hospital da Criança Conceição
Porto Alegre,
RS Brazil
My coauthors and I thank Dr. Vriesman and Dr. Puylaert for their comments about our recently published article "Omental Infarction in Children: Color Doppler Sonography Correlated with Surgery and Pathology Findings" [1]. Two issues have been raised: preoperative diagnosis and management.
Studies published so far have not focused on the accuracy of sonography and CT in the preoperative diagnosis of omental infarction because most of these studies are case reports.
I believe that radiologists should not overestimate the capacity of imaging methods (CT and sonography) to establish a preoperative diagnosis of omental infarction because the most frequent finding—an inflammatory mass—is nonspecific and the characteristic format of the infarcted omentum (cakelike) is not always observed, thus emphasizing the importance of visualizing the normal appendix. Pain is not usually intense in omental infarction and WBC results do not usually indicate infection, but similar clinical and laboratory results may also be found in acute appendicitis.
The focus of our study was not the management of patients with omental infarction. Nonetheless, Vriesman and Puylaert's letter has given us the opportunity to discuss such an important issue. A review of our hospital records showed that no cases of omental infarction were seen during the 10 years before the first case reported in our article. Only recently have more patients with this disease been seen in our hospital; we still do not have any explanation for this fact. Consequently, our surgeons' experience with this disease was practically nonexistent, and the management they adopted was surgical for all patients.
Surgical management is based not only on a 1972 reference [2], but also on a more recent study, one published in 2002 [3], that was mentioned in our article but not by Vriesman and Puylaert in their letter. Other institutions also adopt surgery for all or some patients [4, 5].
My coauthors and I currently adopt a conservative treatment for patients with a preoperative radiologic diagnosis of omental infarction if abdominal pain is not intense, but the identification of the normal appendix is fundamental if pain is intense and WBC results indicate infection.
For patients with intense pain, surgery may bring rapid symptom resolution and reduce hospitalization time. My coauthors and I recently saw an 8-year-old boy with a preoperative sonogram suggestive of omental infarction, WBC indicating infection, and a significant increase in pain intensity over the preceding 48 hr. The surgeon, although aware of the sonographic diagnosis, decided to surgically remove the infarcted tissue so that the child's clinical symptoms would resolve rapidly, which in fact happened in the early postoperative period.
Finally, it is my view that conservative management should be adopted whenever possible. However, as seen in the cases described and according to current knowledge, many times this decision cannot be made based on imaging findings alone.
References
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