Omental Infarction: Causes & Treatment | A 17-Year-Old Girl Case Capsule

2. Residual/reorganizing infarct

The reduction from the original lesion to approximately 2 cm on serial ultrasound supports an evolving/resolving process.

3. Omental torsion

A torsed omental segment can infarct and produce persistent or recurrent localized pain.

When reviewing the CT, specifically look for:

Whirling/convergence of omental vessels toward a vascular pedicle.

A definite whirl/pedicle sign makes torsion more clinically relevant.

4. A new episode

A genuinely new infarction is possible, although it should not be assumed simply because the patient has recurrent pain.

5. Another diagnosis

This is particularly important in a 17-year-old girl.

Recurrent abdominal pain should prompt reassessment for:

• Ovarian torsion
• Ovarian cyst
• Dysmenorrhea/endometriosis
• Gastritis/peptic disease
• Appendicitis
• Mesenteric pathology
• Urinary pathology

The current CT reported no adnexal lesion and a normal appendix, which is reassuring. 

NISTARA JUDAL ct.pdf

Management: Conservative treatment remains the first option in an uncomplicated case

When CT establishes omental infarction and the patient is clinically stable, non-operative management is reasonable.

Treatment is principally supportive:

• Analgesia
• Hydration
• Antiemetics when required
• Oral diet as tolerated
• Serial abdominal examination
• Clinical observation
• Repeat CBC/CRP when clinically indicated

The pediatric literature supports conservative management when the diagnosis is secure and the child/adolescent is clinically stable. Several pediatric series have reported successful non-operative treatment without complications. 

Ultrasound can also be useful for follow-up. In one pediatric series, serial ultrasound demonstrated disappearance of the infarction in all conservatively managed patients. 

But when should we operate?

This is the most important surgical lesson.

Omental infarction itself is not an indication for surgery.

The decision should be based on the patient’s clinical course + imaging + diagnostic certainty.

Consider diagnostic laparoscopy when:

Persistent or worsening pain

Pain remains severe despite adequate conservative treatment, particularly if it is relentless.

Peritoneal signs

Guarding, rebound tenderness or progressive localized peritonism should lower the threshold for surgery.

Clinical deterioration

• Fever
• Rising WBC
• Rising CRP
• Tachycardia
• Sepsis
• Hemodynamic instability

Diagnostic uncertainty

If appendicitis, ovarian torsion, bowel pathology or another surgical condition cannot confidently be excluded.

Definite omental torsion

A clear twisted omental pedicle/whirl sign, particularly when associated with significant persistent pain, makes operative treatment more reasonable.

Pediatric surgical literature has specifically described uncertain diagnosis, intractable/relentless pain and persistent peritoneal findings as indications for operative exploration. 

What does the evidence tell us about conservative versus surgical treatment?

There is still no universally accepted treatment guideline for omental infarction.

A systematic review of CT-diagnosed adult cases found that conservative treatment was used in approximately 73% of patients, with successful symptom resolution in approximately 84% of those treated conservatively. 

However, the evidence has important limitations:

• Most studies are retrospective.
• Many are case reports or small series.
• Pediatric and adult populations are different.
• There is no high-quality randomized trial establishing one treatment as universally superior.

A pediatric series similarly supports a short trial of conservative management, while identifying persistent/intractable pain and peritoneal findings as reasons to operate. 

A recent literature review also emphasizes intractable pain and omental torsion as situations in which surgery becomes more important. 

What about this particular 17-year-old?

This case has several features favoring continued conservative management, provided the clinical examination is reassuring:

Favourable features

• Previous clinical improvement with medical treatment
• Serial USG demonstrated reduction of the lesion
• Current WBC is normal
• Current CRP is normal
• No free fluid
• No bowel obstruction
• No bowel-wall abnormality
• Normal appendix
• No adnexal lesion
• No abscess or collection
• Normal major abdominal vessels. 

NISTARA JUDAL ct.pdf

Therefore:

Recurrent pain alone, in the presence of normal inflammatory markers and an uncomplicated CT appearance, does not automatically justify omentectomy.

The next step should be clinical reassessment and careful review of the CT for evidence of omental torsion.

Should we investigate thrombophilia?

This is an important question in a 17-year-old.

Not routinely in every isolated omental infarction.

I would consider further evaluation when there are additional clues such as:

• Recurrent objectively documented infarction
• Thrombosis at another site
• Previous unexplained venous/arterial thrombosis
• Strong family history of thrombosis
• Unusual thrombotic events
• Clinical suspicion of a systemic hypercoagulable state

The mechanism of OI can involve hypercoagulable states or vascular abnormalities, but this does not mean that every young patient with OI has thrombophilia. 

The Surgical Learning Point

Do not operate on the CT image. Operate on the patient.

A radiologically confirmed omental infarction in a stable adolescent with improving symptoms can usually be observed.

The trajectory is more important than the mere presence of an omental mass.

Think in three questions:

Is the diagnosis secure?

↓

Is the patient clinically improving or deteriorating?

↓

Is there evidence of torsion or another surgical pathology?

This approach prevents unnecessary surgery while maintaining an appropriate threshold for laparoscopy when the clinical course demands it.

Practical Decision Algorithm

17-year-old + localized abdominal pain

↓

US/CECT demonstrates omental infarction

↓

Stable + diagnosis secure + no peritonitis

→ Conservative treatment

→ Analgesia + hydration ± antiemetic

→ Clinical observation

→ Serial US/clinical follow-up when appropriate

↓

Improving

→ Continue conservative management

↓

Persistent severe pain / worsening examination

OR

Rising inflammatory markers

OR

Peritonitis

OR

Diagnostic uncertainty

OR

Definite omental torsion

→ Diagnostic laparoscopy ± resection of infarcted omentum

Key Learning Lessons from This Case

• Omental infarction should be included in the differential diagnosis of acute abdominal pain in adolescents.

• It can mimic appendicitis and other common surgical conditions.

• CT can establish the diagnosis and potentially prevent unnecessary surgery.

• Ultrasound is valuable not only for diagnosis but also for follow-up in children and adolescents.

• A decreasing lesion on serial ultrasound supports an evolving/resolving process.

• Normal WBC and CRP during recurrent pain are reassuring but do not replace clinical examination.

• Always review the CT specifically for an omental whirl/torsion sign.

• In a young female, ovarian pathology must remain in the differential diagnosis.

• Routine thrombophilia testing is not justified solely because the patient is young; recurrent or systemic thrombotic features should guide further evaluation.

• Persistent, relentless pain, peritonitis, diagnostic uncertainty or definite torsion are the main reasons to consider laparoscopy.

Bottom line

For a clinically stable 17-year-old with CT-proven uncomplicated omental infarction, conservative management with active clinical surveillance is a reasonable first-line strategy. Recurrent pain should trigger reassessment—not automatic surgery. The decision to operate should be driven by the clinical course, peritoneal findings, inflammatory response, diagnostic uncertainty and evidence of omental torsion.

Suggested SEO title

Omental Infarction in a 17-Year-Old Girl: A Case Capsule on Causes, Conservative Management and Indications for Surgery

Top keywords

omental infarction, omental infarction in children, omental infarction adolescent, omental torsion, recurrent abdominal pain, acute abdomen adolescent, conservative management omental infarction, laparoscopic omentectomy, CT diagnosis omental infarction, pediatric acute abdomen

Evidence base: pediatric case series and reviews support imaging-based diagnosis and an initial conservative approach in clinically stable patients, while recognizing persistent pain, peritoneal findings and torsion as important reasons for surgery.