Abstract
A 9-year-old boy was referred to the emergency department by his GP with abdominal symptoms. He complained of periumbilical pain for 3 days which had gradually radiated to his right iliac fossa in the 12 hours before presentation. The pain was colicky, intermittent in nature and exacerbated by moving or eating. There was associated anorexia and nausea but no vomiting. Bowel pattern had remained normal throughout and no urinary symptoms were noted. On presentation he graded the pain as 10/10. A collateral history was taken from his mother who verified the symptoms. There was no history of trauma.
On examination he was flushed, dehydrated but apyrexial. Cardiorespiratory examination was normal. Abdominal examination revealed tenderness and guarding in the right iliac fossa. Bowel sounds were normal and he had a positive Rovsing's test. Laboratory investigations revealed a normal full blood count (white cell count of 8.76 × 106), a normal renal profile and a normal serum amylase. Erythrocyte sedimentation rate was marginally elevated at 18 mm/hr. Urinalysis was normal.
A clinical diagnosis of appendicitis was made. A Lanz incision was made and on opening the peritoneum blood-stained fluid was noticed. On close inspection the appendix looked healthy and a routine appendicectomy was carried out. The incision was extended medially and the caecum and small bowel were fully inspected with no pathology identified. Near the right hepatic flexure an area of necrotic omentum was identified with thrombosed veins. Another area of omentum was seen which had twisted upon itself (omental torsion). This was excised and tied with vicryl sutures. Postoperatively, the patient went home on day 3 after an uneventful recovery. Histopathology revealed a normal appendix. The excised omentum revealed fat necrosis and ischaemic changes consistent with torsion (Figure 1).