Presentation
Right abdominal pain.
Patient Data
The right part of the greater omentum is thickened and shows fat stranding, with hyperdense linear opacities representing engorged blood vessels. It displaces the ascending colon and several ileal loops medially. Small amount of intraperitoneal free fluid - in the hepatorenal fossa, around the lower edge of the liver, in the right lower abdomen, in the lesser pelvis, and in the left paracolic gutter.
The appendix is postileal in position, measures 6 mm in diameter, has thin walls, and contains gas locules. Tiny appendicolith in its distal lumen. No periappendiceal fat stranding.
Innumerable mesenteric lymph nodes, nonenlarged, prominent in right lower abdomen (maximum 8 mm thick).
Small fat-containing umbilical hernia.
Images acquired during the abdominal ultrasound that preceded the CT exam show a thickened hyperechoic omentum and a locule of fluid in the right lower quadrant.
Case Discussion
A toddler presented with right abdominal pain for the past couple of days. Her right abdomen was tender, possibly with rebound tenderness. Labs: CRP 32, very mild leukocytosis without a left shift. The appendix was not appreciated on ultrasonography, so contrast-enhanced CT was done. On CT, the appendix appeared normal and an unexpected omental infarction was deemed the cause of pain. The ultrasound exam was revisited and, sure enough, a thickened, hyperechoic omentum could be seen subjacent to the abdominal wall.
This case underscores the importance of including omental infarction in the differential diagnosis of abdominal pain, especially right lower quadrant pain, in children and searching for it actively on ultrasound, even if it is considered quite uncommon in this population. As it turns out, even young children can become afflicted. Predisposing factors include obesity (as in this case), abdominal trauma, and intestinal hypermotility.
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