|Year : 2018 | Volume
| Issue : 4 | Page : 171-174
Idiopathic isolated omental panniculitis presenting with intestinal obstruction
Vipul D Yagnik
Department of Surgical Gastroenterology, Ronak Endo-Laparoscopy and General Surgical Hospital, Patan, Gujarat, India
|Date of Submission||24-Oct-2017|
|Date of Decision||03-Dec-2017|
|Date of Acceptance||03-Jan-2018|
|Date of Web Publication||22-Aug-2018|
Dr. Vipul D Yagnik
77, Siddhraj Nagar, Rajmahal Road, Patan - 384 265, Gujarat
Source of Support: None, Conflict of Interest: None
Intra-abdominal panniculitis is a rare condition characterized by intraperitoneal lipodystrophy that may manifest as a necrotic adipose lump causing symptoms due to inflammation or mass effect. Although this condition tends to primarily affect the root of the mesentery, it may affect any part of the peritoneum, including the omentum. However, isolated omental panniculitis, in which no other site is affected, is a very rare form of intra-abdominal panniculitis and only eight cases have been reported in the literature so far. Mesenteric panniculitis, especially in the late fibrous stage of retractile mesenteritis, is known to occasionally cause intestinal obstruction by virtue of its relation to the bowel. However, omental panniculitis has only been reported to cause nonspecific inflammatory symptoms. We present a case of isolated omental panniculitis of indeterminate etiology. To the best of our knowledge, this is the first such case reported to present with intestinal obstruction.
Keywords: Obstruction, omental panniculitis, sclerosing mesenteritis, surgery
|How to cite this article:|
Yagnik VD. Idiopathic isolated omental panniculitis presenting with intestinal obstruction. Formos J Surg 2018;51:171-4
| Introduction|| |
Isolated omental panniculitis, as a subtype of intra-abdominal panniculitis defined by the absence of evidence of pancreatitis, inflammatory bowel disease, and extra-abdominal fat necrosis, is even rarer with only eight cases reported in the English language literature till date. Here, we report a case of isolated idiopathic omental panniculitis presenting with intestinal obstruction.
| Case Report|| |
A 65-year-old male patient presented with abdominal pain and vomiting. He complained of abdominal distension and had not passed stools for the last 2 days. Pain was sudden onset severe colicky in the left upper abdominal quadrant and aggravated by movement. He had no significant past medical or surgical history notably similar type of abdominal pain, intra-abdominal malignancy, and abdominal surgery. Physical examination revealed a heart rate of 140/min and blood pressure of 80/50 mmHg. Abdominal examination revealed abdominal distension, tenderness in the left lumbar region, and a palpable lump in the left lumbar region. Laboratory investigations revealed leukocytosis (22,100/cu mm), an average random serum glucose (110 mg/dL), elevated serum creatinine (3.89 mg/dL), elevated erythrocyte sedimentation rate (55 mm/h), and increased C-reactive protein levels (110 mg/L). X-ray of the abdomen revealed small bowel obstruction [Figure 1]. Abdominal ultrasonography was indeterminate due to the presence of excessive bowel gas. As the patient presented in sepsis with overt bowel obstruction, we suspected bowel strangulation or gangrene. We therefore decided against performing a computed tomography (CT) abdomen as it would not change our decision for exploratory laparotomy and only add to the delay. After initial resuscitation, exploratory laparotomy was performed, which revealed a large omental lump 15 cm × 13 cm × 10 cm in size, which was adherent to the small bowel [Figure 2] and had a yellowish and nodular external surface [Figure 3]. The adjacent tissues were dissected without injuring the bowel. Other abdominal organs were examined and found to be normal, notably the small bowel mesentery, pancreas, and sigmoid mesocolon. Histopathological examination of the mass revealed thick fibrous encapsulation; it was composed of lobules of adipose tissue separated by thick fibrous septae with congested and dilated blood vessels [Figure 4]. A focal area of fat necrosis and xanthomatous inflammation was present at the periphery, with the collection of fat-laden macrophages consistent with omental panniculitis [Figure 4]. We performed other investigations, such as antinuclear antibody, rheumatoid factor, lupus anticoagulant, and IgG-4, to determine the underlying cause, but all results were within normal limits. The postoperative course was unremarkable. The patient was discharged on the 7th postoperative day, and no problems were noted in 4-month follow-up.
|Figure 1: X-ray abdomen standing revealed multiple air-fluid level suggestive of acute small bowel obstruction|
Click here to view
|Figure 2: A large omental lump of 15 cm × 13 cm × 10 cm was adherent to the small bowel|
Click here to view
|Figure 4: Hematoxylin and eosin stain showing thick fibrous encapsulation; the mass is composed of a lobule of adipose tissue separated by thick fibrous septae with congested and dilated blood vessels, a focal area of fat necrosis, and xanthomatous inflammation, with the collection of fat-laden macrophages|
Click here to view
| Discussion|| |
Isolated omental panniculitis, in which the omentum is the only site affected, is a very rare form of intra-abdominal panniculitis. This may be due to the passive functional role of the omentum, which spares it from most pathological involvement.
In the small intestinal mesentery, changes are more common on the left side, which are indicative of the involvement of the jejunal mesentery, but the mesocolon, omentum, retroperitoneum, or pelvis are very rarely involved. Katz et al. have defined the primary diagnostic criteria for intra-abdominal panniculitis as follows: (a) Diffuse single or multiple mass-like fatty lesions in the mesentery, retroperitoneum, omentum, or pelvis; (b) histological confirmation of fat necrosis with inflammatory infiltrates or infiltration of foamy lipid-laden macrophages; and (c) no evidence of pancreatitis, inflammatory bowel disease, or extra-abdominal fat necrosis (Weber–Christian disease). Isolated omental panniculitis is very rare, and only six cases have been reported in the literature till 2015. We did careful literature search using the keyword omental panniculitis and found 2 more cases. Thus, eight cases have been reported so far.
In this case, the patient presented with signs and symptoms of intestinal obstruction. Mesenteric panniculitis has been reported presenting with bowel obstruction. The initial clinical presentation of mesenteric panniculitis is abdominal pain, fever, and malaise, and it may later present as an abdominal lump and/or with symptoms of intestinal obstruction. A careful search of the English language literature did not reveal any report of isolated omental panniculitis presenting with intestinal obstruction. This rarity may be due to the observation that sclerosing mesenteritis, the stage of mesenteric panniculitis most associated with bowel obstruction, is the final stage of the disease process where fibrosis is predominant, while panniculitis is the intermediate stage associated more with inflammation. In addition, mesenteric panniculitis is more likely to produce a mass effect on the adjacent bowel while this is unlikely in isolated omental panniculitis.
The hallmark of mesenteric panniculitis is a focal area of increased density of mesenteric fat tissue surrounded by a pseudocapsule, which is referred to as a misty mesentery, first described by Mindelzun et al. Other signs observed on CT that indicate mesenteric panniculitis are the fat halo or fat-ring sign and the tumoral pseudocapsule sign.
The guidelines for the treatment of symptomatic forms of this condition are not well established. About 24% of mesenteric panniculitis presents with intestinal obstruction. This is because of the anatomical relationship causing a mass effect and/or adhesional kinks. This is unlikely to occur in purely omental disease and is borne out by the fact that there are no reports of omental panniculitis causing bowel obstruction before our report. Akram et al. state that approximately 50% of the patients with sclerosing mesenteritis might not require any treatment. Patient with nonobstructive symptoms might benefit from tamoxifen/prednisone combination treatment. Surgical treatment is indicated for either unresolved bowel obstruction or advanced inflammatory reaction.
It has been suggested that mesenteric panniculitis may be a nonspecific response to intra-abdominal malignancy; therefore, investigation and close follow-up is warranted to search for hidden malignancy.
| Conclusion|| |
We report a case of isolated omental panniculitis that presented as intestinal obstruction and was diagnosed on postoperative biopsy. In our case, the need for laparotomy was dictated by the intestinal obstruction, and there was no preoperative indicator or suspicion of this condition. To the best of our knowledge, this patient represents the first reported case of bowel obstruction caused by isolated omental panniculitis.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form the patients have given their consent for their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
I would like to acknowledge the help provided by Dr. Sushil Dawka (professor of surgery, Mauritius) for his kind help in editing the manuscript. I would also like to acknowledge the help provided by Dr. Bhavna Mehta and Dr. Palak Patel (Supratech micropath laboratory, Ahmedabad) for histopathological photograph.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Rumman N, Rumman G, Sharabati B, Zagha R, Disi N. Mesenteric panniculitis in a child misdiagnosed as appendicular mass: A case report and review of literature. Springerplus 2014;3:73.
Katz ME, Heiken JP, Glazer HS, Lee JK. Intraabdominal panniculitis: Clinical, radiographic, and CT features. AJR Am J Roentgenol 1985;145:293-6.
Park JS, Kim SH, Yoon BW, Oh BS, Yoon DS, Hong N, et al
. Idiopathic isolated perigastric omental panniculitis. Korean J Helicobacter Up Gastrointest Res 2015;15:178-81.
Parra-Davila E, McKenney MG, Sleeman D, Hartmann R, Rao RK, McKenney K, et al.
Mesenteric panniculitis: Case report and literature review. Am Surg 1998;64:768-71.
Chawla S, Yalamarthi S, Shaikh IA, Tagore V, Skaife P. An unusual presentation of sclerosing mesenteritis as pneumoperitoneum: Case report with a review of the literature. World J Gastroenterol 2009;15:117-20.
Mindelzun RE, Jeffrey RB Jr., Lane MJ, Silverman PM. The misty mesentery on CT: Differential diagnosis. AJR Am J Roentgenol 1996;167:61-5.
Akram S, Pardi DS, Schaffner JA, Smyrk TC. Sclerosing mesenteritis: Clinical features, treatment, and outcome in ninety-two patients. Clin Gastroenterol Hepatol 2007;5:589-96.
Kipfer RE, Moertel CG, Dahlin DC. Mesenteric lipodystrophy. Ann Intern Med 1974;80:582-8.
[Figure 1], [Figure 2], [Figure 3], [Figure 4]