Presentation guided by the child’s age, clinical presentation and

Presentation

A 4 year-old
Lebanese girl referred to the hospital for a history of persistent abdominal
started two days ago abruptly, originating in the periumbilical area with right
flank irradiation accompanied by nausea and decreased oral intake, increased by
walking and ambulation and accompanied by stool retention. There is no fever,
vomiting, respiratory tract infection symptoms or dysuria neither abdominal
trauma. The mother reported 10 days ago a brief episode of colicky abdominal
pain with vomiting and diarrhea that was treated by oral Cefixime for resumed
bacterial gastroenteritis and subsided within few days without complication
till the present story. She has no history of recurrent abdominal pain or
urinary tract infection neither constipation. Family history is only revealing
foe an aunt diagnosed as having familial Mediterranean fever, there is no
consanguinity between parents.

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Physical
examination, reveal an anxious and ill looking, well-nourished girl, with
forward bending with slow walking, the abdomen is slightly distended with
decreased bowel sound and diffuse tenderness and guarding especially
exacerbated on right sub hepatic area, she is febrile at 38.7 degree Celsius,
otherwise there is no masses or skin rash.

Laboratory
tests revealed leukocytosis up to (15.07/?l  15.07×109/L),  with increased of neutrophils percentage to 74% and increased
of C reactive Protein (CRP) to 91 mg/ dl (normal value less than 10 mg/dl), the
liver function tests and the renal function tests are normal as well as the
urine analysis.

The standing
abdominal X-Ray reveal a shift of gas distribution fig 1

And emergent
abdominal echography revealed few mesenteric adenitis with free peritoneal
fluid and edematous changes of the abdominal wall of the right flank.

Discussion:

Acute
Abdominal pain is a frequent complaint in childhood that requires an emergent
evaluation either in the emergency department of the private clinic, causes are
variable and could range from some self-limited minor disorders, such as
constipation, gastroenteritis, or viral syndrome. To others challenging and
possibly life-threatening conditions that requires prompt evaluation and quick
diagnosis to prevent imminent morbidities such as acute appendicitis,
intestinal obstruction or volvulus and peritonitis. The diagnosis is usually
oriented and guided by the child’s age, clinical presentation and complete
history and physical examination.

The
differential diagnosis of our case comprises: acute appendicitis, Mesenteric
lymphadenitis, bacterial and viral gastroenteritis, hepatitis, urinary tract
infection especially pyelonephritis and abdominal wall trauma or infection.

The
laboratory tests showed increased inflammatory markers with normal findings on
urine analysis excluding urinary tract infection and the abdominal
ultrasonography as well as the abdominal radiography revealed no specific
findings except for abdominal wall thickening.

Actual
Diagnosis

Giving the persistence
of the severe right flank pain and the toxic appearance of the girl, an
abdominal CT scan was performed with Intravenous contrast only, because the
girl was unable to drink and to keep her NPO for possible surgery, and it
showed a solid mass localized beneath the right flank abdominal wall that
raises the possibility of a surgical abdomen process that needs exploration.

Fig 2 &
3

The girl was
sent to the operative room for an explorative laparotomy, a right paraumbilical
horizontal incision was performed, the entire bowels and the appendix are
totally explored and screened and we succumb onto a part of the right omentum
that was found to be twisted making a complete volvulus with some necrosis, so
it was resected along with an appendectomy and all were sent for the pathology
examination.

Fig 4&5

The
condition

Volvulus
with secondary infarction of the omentum is a very rare disease in children and
constitutes less than 0.1% of causes of acute abdominal pain, rarely it is
considered in the differential diagnosis of surgical abdominal pain and usually
come into diagnosis during an explorative laparotomy for suspected
appendicitis.

Causes of
omental infarction can be classified into primary or idiopathic, when there is
no abnormal anatomic or structural conditions found in association and
secondary when there are preexisting anomalies, localized in the abdomen like
adhesions, tumors, inflammatory conditions such as inflammatory bowel diseases,
and different types of hernias that lead to inflammation and adhesion in left
untreated.

Most cases of the omental infarction were found
located on the right side of the abdomen, a finding that could be presumed to
the greater mobility and large size of the right omentum compared to the left
side. Inciting factors include blunt abdominal trauma, increased
intra-abdominal pressure as occur in case of constipation, severe coughing and
heavy meal, possibly by compromising the omental blood flow.

Diagnosis
and Treatment

Clinical
diagnosis of omental volvulus and infarction is difficult and it should be
suspected in atypical clinical presentation of appendicitis, important
presenting symptoms are acute abdominal pain with severe abdominal tenderness
mainly localized to the right flank or to the right para-umbilical region
without any irradiation and with sharp exacerbation upon movement or palpation.
Usually there is little nausea, anorexia and no vomiting and the fever could be
low grade or absent. As para clinical investigations, the blood tests could
show mild leukocytosis with neutrophils predominance and mild elevation of the
CRP and ESR.

The
abdominal echography may show nonspecific findings such as free peritoneal
fluid and abdominal wall edema and could localize the solid hyperechoic mass
close to the abdominal wall. The CT scan is more accurate than the ultrasound
and may show the characteristic signs of omental infarction as in the form of
concentric linear strands, so an accurate preoperative diagnosis can be made before
surgical intervention. But unfortunately as in our cases the final diagnosis
may not be definitive until the explorative laparotomy which will disclose a
fatty hemorrhagic mass with free peritoneal fluid and normal bowel and appendix
during the full abdominal exploration.

Management
and Patient course

Laparotomy and resection of the infarcted omentum is
mandatory, many authors suggested a conservative approach in uncomplicated
cases but surgical intervention is associated with quick recovery with less
complications and pain; in our case, the vague clinical presentation and
non-conclusive investigations and imaging tests, prompt us to proceed with the
laparotomy which resolved the mystery of the girl’s severe abdominal pain to be
an idiopathic omental volvulus with infarction which was resected without
complications

Lessons for the Clinicians:

Omental infarction is one
of the differential diagnosis of acute abdomen especially when there is
atypical presentationAbdominal CT scan is most
helpful and may show the characteristic lesions and findingsSurgery is imperative as
many cases are not revealed till the laparotomy Resection is the good
choice of the infarcted omentum and hasten the recovery process and prevent
further complications

Suggested Readings

Safioleas,
M., Stamatakos, M., Giaslakiotis, K. et al. Int Semin Surg Oncol (2007) 4: 19.
https://doi.org/10.1186/1477-7800-4-19Fawzia Elgharbawy, Khalil Salameh, Talal Al Rayes et
al. Dove press/ pediatric case. Volume 2017:8. https://doi.org/10.2147/PHMT.S133409