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Infarction of the lesser omentum

Author(s)

Ricardo Correia; Márcio Rodrigues; André Carvalho; Madalena Pimenta

Hospital Sao Joao;
Alameda Professor Hernâni Monteiro
4200-319 Porto;
Email:ricardogdc@sapo.pt

Patient

female, 31 year(s)

Clinical History

A female patient presented with sharp epigastric pain and features of an acute abdomen in the emergency department. There were no vomiting episodes, changes in bowel habits or symptoms related to the genitourinary tract. Laboratory results were normal, including hepatic and pancreatic values, except for mild elevated C-reactive protein (42.4 mg/L).

Imaging Findings

The abdominal radiograph did not reveal any pathological findings, being non-contributive to this case.

Abdominal ultrasound (US) demonstrated a hyperechoic, painful and non-compressible lesion in the epigastrium, between the left hepatic lobe and the stomach (Fig. 1). The high echogenicity of the lesion suggested a lipomatous origin and it was hard to separate it from the adjacent pancreas (Fig. 2).
No vascular flow was found on colour Doppler examination and there was posterior attenuation on high-resolution probe evaluation (Fig. 3-4).

On contrast-enhanced computed tomography (CT), the presence of an epigastric fatty lesion distinct from the pancreas was confirmed. Hyperattenuating streaks within the lesion were compatible with inflammatory changes (Fig. 5).

Reconstruction views revealed mass effect on surrounding organs and allowed to centre the lesion in the lesser omentum. Apart from a small amount of free fluid in the Douglas pouch, all other abdominal and pelvic structures were unremarkable (Fig. 6-7).

Discussion

Infarction of the lesser omentum is a very rarely reported cause of acute abdomen [1]. It belongs to the spectrum of “Intraperitoneal Focal Fat Infarction” (IFFI), a term that was introduced to unify abdominal conditions resulting from infarction and/or torsion of the greater or the lesser omentum, an epiploic appendix or the falciform ligament. All these conditions share clinical and radiological features, as well as treatment and prognosis [2, 3].

Omental infarction can have primary or secondary causes. While the former usually result from a vascular event, the latter may occur trauma or a surgical procedure. [4]

Patients with infarction of the lesser omentum usually present with sharp epigastric pain that increases in intensity over time. Vomiting is not common but nausea can be experienced. On physical examination, signs of peritoneal irritation focused on the epigastrium can mimic an acute surgical abdomen. Inflammatory markers such as leukocytosis and mildly increased C-reactive protein level are also common. [1, 5, 6]

On ultrasound, a solid hyperechoic and hyperattenuating lesion that is painful and non-compressible, is usually found in the epigastric area, between the left hepatic lobe and the stomach [1, 5, 6]. Distinguish an infarction of the lesser omentum from a pancreatic tumour based solely on ultrasound findings can be challenging [7].

On CT, a fatty inflammatory lesion in the anatomic area of the lesser omentum is invariably present. Hyperattenuating streaks that most likely represent fibrous bands or dilated thrombosed vessels are also a common feature. [1, 5, 6]

Imaging findings on both ultrasound and CT have a high sensitivity and specificity for the diagnosis of IFFI cases. However, diagnosis with CT is safer because findings are more consistent and specific, and this technique can rule out other acute abdominal conditions more safely. [2, 3]

As conservative medical treatment leads to favourable clinical evolution in most cases, the main role of the radiologist is to establish the precise diagnosis and avoid unnecessary surgery. No follow-up imaging is usually required. [2, 3, 5]

Our patient presented with the most common clinical and imaging findings described in the literature, which allowed a precise diagnosis and a conservative management. As a consequence, we do not have histopathological confirmation, but the final diagnosis of infarction of the lesser omentum seems unequivocal. This is also supported by the complete recovery of the patient's symptoms after administration of analgesic and non-steroid anti-inflammatory agents. No imaging follow-up was performed.

Final Diagnosis

Differential Diagnosis List

References

[1]

Mavroeidis VK, Matthioudakis DI, Economou NK, Karanikas ID. (2013) Primary Lesser Omentum Torsion - An Extremely Rare Cause of Acute Abdomen and a Very Uncommon Subtype of Intraperitoneal Focal Fat Infarction (IFFI): Case Report and Review of the Literature. Journal of Medical Cases 4(7):499-503
[2]

van Breda Vriesman AC, Lohle PN, Coerkamp EG, Puylaert JB. (1999) Infarction of omentum and epiploic appendage: diagnosis, epidemiology and natural history. European Radiology 9(9):1886-1892
[3]

Coulier B. (2010) Contribution of US and CT for diagnosis of intraperitoneal focal fat infarction (IFFI): a pictorial review. JBR-BTR 93(4):171-185
[4]

Kamaya A, Federle MP, Desser TS. (2011) Imaging manifestations of abdominal fat necrosis and its mimics. Radiographics 31(7):2021-34
[5]

Coulier B, Van Hoof M. (2004) Intraperitoneal fat focal infarction of the lesser omentum: case report. Abdominal Imaging 29(4):498-501
[6]

Coulier B. (2006) A new case of intraperitoneal fat focal infarction (IFFI) of the lesser omentum. European Radiology 16(4):954-955
[7]

Kim HC, Yang DM, Jin W, Joh JH. (2011) Infarction of lesser omental fat mimicking an exophytic pancreatic tumor by sonography. Journal of Clinical Ultrasound 39(7):412-414

Citation

Ricardo Correia; Márcio Rodrigues; André Carvalho; Madalena Pimenta (2017, Jun 18).

Infarction of the lesser omentum, {Online}.

URL: http://www.eurorad.org/case.php?id=14614

DOI: 10.1594/EURORAD/CASE.14614

Public License

This work is licensed under the Creative Commons Attribution-NonCommercial-ShareAlike 4.0 International License.

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Published 18.06.2017
DOI 10.1594/EURORAD/CASE.14614
Section Abdominal Imaging
Case Type Clinical Cases
Views 285
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Figure 1
Abdominal Ultrasound

Ultrasound evaluation of epigrastic area shows a hyperechoic lesion (arrow) between the left hepatic lobe (L) and the stomach (S). This lesion was painful and noncompressible. P: Pancreas; A: Aorta; IVC: Inferior Vena...

Area of Interest: Abdomen; Imaging Technique: Ultrasound; Procedure: Diagnostic procedure; Special Focus: Inflammation;
Figure 2
Abdominal Ultrasound

On ultrasound the echogenic aspect of the lesion (arrow) is suggestive of being lipomatous, and it cannot be easily discriminated from the adjacent hyperechoic pancreas (P).

Area of Interest: Abdomen; Imaging Technique: Ultrasound; Procedure: Diagnostic procedure; Special Focus: Tissue characterisation;
Figure 3
Colour Doppler Ultrasound

No vascular flow is present within the lesion on colour Doppler ultrasound examination.

Area of Interest: Abdomen; Imaging Technique: Ultrasound-Colour Doppler; Procedure: Diagnostic procedure; Special Focus: Inflammation;
Figure 4
High-resolution Ultrasound

High-resolution probe ultrasound evaluation shows attenuation on the posterior aspect of the lesion (*).

Area of Interest: Abdomen; Imaging Technique: Ultrasound; Procedure: Diagnostic procedure; Special Focus: Inflammation;
Figure 5
Axial contrast-enhanced CT (soft tissue window)

A fatty lesion (arrow) with hyperattenuating streaks is seen between the left hepatic lobe and the lesser gastric curvature.

Area of Interest: Abdomen; Imaging Technique: CT; Procedure: Diagnostic procedure; Special Focus: Ischaemia / Infarction;
Figure 6
Coronal reconstruction contrast-enhanced CT (soft tissue window)

The lesion shows mass effect on lesser gastric curvature and is situated between the liver (L) and the stomach (S), an area that corresponds to the lesser omentum.

Area of Interest: Abdomen; Imaging Technique: CT; Procedure: Diagnostic procedure; Special Focus: Ischaemia / Infarction;
Figure 7
Sagittal reconstruction contrast-enhanced CT (soft tissue window)

The hyperattenuating lesion on a sagittal view (arrow). Also small amount of free fluid is seen in the Douglas pouch (*).

Area of Interest: Abdomen; Imaging Technique: CT; Procedure: Diagnostic procedure; Special Focus: Ischaemia / Infarction;

Figure 1

Abdominal Ultrasound

Ultrasound evaluation of epigrastic area shows a hyperechoic lesion (arrow) between the left hepatic lobe (L) and the stomach (S). This lesion was painful and noncompressible. P: Pancreas; A: Aorta; IVC: Inferior Vena Cava.

Figure 2

Abdominal Ultrasound

On ultrasound the echogenic aspect of the lesion (arrow) is suggestive of being lipomatous, and it cannot be easily discriminated from the adjacent hyperechoic pancreas (P).

Figure 3

Colour Doppler Ultrasound

No vascular flow is present within the lesion on colour Doppler ultrasound examination.

Figure 4

High-resolution Ultrasound

High-resolution probe ultrasound evaluation shows attenuation on the posterior aspect of the lesion (*).

Figure 5

Axial contrast-enhanced CT (soft tissue window)

A fatty lesion (arrow) with hyperattenuating streaks is seen between the left hepatic lobe and the lesser gastric curvature.

Figure 6

Coronal reconstruction contrast-enhanced CT (soft tissue window)

The lesion shows mass effect on lesser gastric curvature and is situated between the liver (L) and the stomach (S), an area that corresponds to the lesser omentum.

Figure 7

Sagittal reconstruction contrast-enhanced CT (soft tissue window)

The hyperattenuating lesion on a sagittal view (arrow). Also small amount of free fluid is seen in the Douglas pouch (*).

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