[size=20px]A 10 year old girl presents with acute onset of right sided abdominal pain. A normal appendix is found during diagnostic laparoscopy, and the ovaries and terminal ileum appear normal. Which of the following should also be examined before finishing the operation?

 

A spleen

 

B transverse colon

 

C omentum

 

D kidney

 

E rectum

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Omentum

C as omental cyst may be twisted or ruptured

correct answer

C omentum

 

Abdominal pain is a very common presentation for children and leads to a large number of ED visits. From a surgical standpoint, acute appendicitis is the most common diagnosis and remains the one that must be evaluated or ruled out. Omental torsion is a rare condition that can present with acute abdominal pain in children. the etiology is unknown in most cases (primary torsion), but may occur secondary to previous operations or inflammatory conditions causing adhesions. While difficult to diagnose preoperatively, CT scan and even ultrasound evaluations can be diagnostic. In certain cases with smaller degrees of torsion or infarction, the use of anti inflammatory medication (ibuprofen) may be therapeutic.

 

In most cases, the diagnosis is made during exploration for acute abdominal pain and the suspicion for appendicitis. In the setting of a normal appendix and ovary in a female, there should be an evaluation of the omentum to rule out the rare torsion or infarction. When diagnosed, partial omentectomy would be recommended. Rarely, a large portion of the omentum may be involved that necessitates a near total omentectomy.

 

Evaluation of the spleen, kidney, rectum or colon in this clinical scenario would be very unlikely to yield a diagnosis. A comprehensive evaluation in the setting of a normal appearing appendix should include a systematic review of the ovaries (in a female), ileum for terminal ileitis as well as a Meckel diverticulum. As described, the omentum must be examined as well. In addition, the right colon may have a diverticulum, or there may be a foreign body induced intestinal perforation.

C