primary acute epiploitis

PRIMARY ACUTE EPIPLOITIS*

V. L. SCHRAGER, M.D., P.A.c.s., AND S. BERGEN, M.D.

CHICAGO, ILL.

P RIMARY acute epiploitis is an inff ammatory pseudo-tumor of the omentum, to a11 appearances not

connected with any demonstrabIe intra- peritonea1 pathology at the time of expIora- tion. Both French and German Iiterature speak of epipIoitis when deaIing with inffammatory processes of the omentum, and we found no description of this entity under the name omentitis. EpipIoon is the Greek synonym of the Latin omentum and, as in the case of appendicitis, omentitis wouId be a hybrid term, coupling a Greek suffix with a Latin word.

The condition was first observed by Lucas Champion&e1 in 1892 in connection with herniotomies, in which the omenta1 mass was either found in an oId hernia1 sac, or deveIoped within a short time of the operation. He found 2 cases of epipIoitis in a series of 275 herniotomies. The observation of Lucas Champion&e stimuIated a number of subsequent reports in the French Iiterature by Reynier, Sauget, Morestin, Forgue, Monod, WaI- ther, and others. PCan,2 on the other hand, faiIed to find omenta1 tumors other than cysts, Iipoma, tubercuIosis and carcinoma. In the German Iiterature, there are three important pubIications, viz: that of J. SchnitzIer,3 who coIIected a11 the cases prior to 1900 and added a few cases of his own, bringing the total number to 24; that of H. Braun,4 who added 8 cases, and that of D. G. Zessas,5 who was abIe to coIIect 44 cases.

In the Iight of the protective abiIity of the omentum by way of absorption and bactericida1 power, it is somewhat confus- ing that the omentum itseIf shouId faI1 victim to infection. There is considerabIe controversy concerning the “ inteIIigent mobiIity ” of the omentum and its migra-

tion toward inff ammatory areas. SeveraI physioIogists deny such active mobiIity and expIain omenta1 dispIacements by passive movements of the body, intestina1 peristaIsis and diaphragmatic excursions. GoIdschmid and SchIoss,6 Vaughan,7 and Buxton and Torey,* who studied the absorptive and bactericida1 power of the omentum, faiIed to prove automotive or ameboid movements, or negative or posi- tive chemotaxis. Arnaudg credits the omen- turn with severa definite functions: it fixes microscopic bodies, it surrounds Iarge immobiIe foreign bodies, it possesses so- caIIed “inteIIigent mobiIity,” it has secre- tory powers, it reguIates the isotonicity and maintains the steriIity of the peritonea1 cavity. In a discussion in Queries and Minor Notes, lo it is stated that the en- gulfing of foreign bodies by the omentum and its attachment to inflamed areas is simpIy due to “production of a Iayer of fibrin at the point of contact.” It is further stated that the omentum has greater power of exudation and fibrin production than the peritoneum, which aIso appIies to the bactericida1, phagocytic, and tryptic activ- ity. It is quite defIniteIy estabIished that omental excursions are passive and that its adhesive properties are due to exudation.

The omentum under discussion is the great omentum, one of the three omenta, viz: the gastrocoIic (great qmentum), the gastrohepatic (Iesser omentum) and the gastrospIenic.

In the French literature, the etioIogy is charged to Iigation of omenta1 flaps with siIk, chiefly in connection with hernia operations. WhiIe H. Braun” does not deny this etioIogy, he observed epiploitis after hernia operations when catgut was used. As a matter of fact, fragments of both catgut and siIk were found in old necrotic

* From the SurgicaI Department of the Mt. Sinai Hospital, Chicago.

45

46 American JournaI of Surgery Schrager & Bergen-EpipIoitis APRIL. 1933

omenta1 stumps. He considers manipuIa- tion of the inflamed otientum of primary importance, irrespective of the type of suture materiaI used. In a discussion at the Paris Society of Surgery, C. Monodll bIamed siIk in Iigations of the omentum and recommends catgut instead. J. Schnitz- Ier3 traces the origin of epipIoitis to the incompIete Iigation of an inflamed omenta1 segment with siIk. E. HoIIInder expressed preciseIy the same view, before the BerIin Society of Surgery, March IO, 1913, on the ground that it does not compIeteIy necrotize omenta1 stumps but mereIy causes hemostasis. He, therefore, suggested individua1 Iigation of bIood vesseIs instead of Iigation en masse. Kiittner12 suspects that in some cases, the suture materia1 may not have been suffIcientIy steriIized; aIso, that Iigation of inflamed omenta1 segments may go on to a more extensive infection.

As a ruIe, epipIoitis foIIows resection of buIky and adherent omentum in oId her- nias. However, epipIoitis may exist inde- pendentIy of resection of the omentum. In a case of H. Braun, an operation for incarcerated femora1 hernia, in which there was no omentum in the sac, was foI- Iowed eIeven weeks Iater by an inffammatory omenta1 mass, 15 cm. in diameter.

EpipIoitis occurs most commonIy in middle-aged individuaIs usuaIIy among fat peopIe, and in most cases foIIows a previous abdomina1 section or herniotomy.

The source of the inflammation may vary. Schmieden13 ascribes epipIoitis to circuIatory disturbances, either thrombosis, emboIism, hemorrhages, or torsion of the omentum, sufficient to cause pathoIogic changes but not death of the tissues. Adams’14 case was secondary to “no detect- abIe abdomina1 Iesion” and concIudes that it was “probabIy emboIic.” Pantzer15 considers epipIoitis haematogenous in origin. He states that ordinariIy bacteria undergo hemoIytic destruction in the omentum, “without Ieaving any anatomic trace of their visitation on the tissue of the omen- turn.” If this process does not take pIace, 0mentaI infection ensues.

WhiIe it is generaIIy agreed that the contamination of the omentum is secondary to diffuse or IocaIized peritonitis, or pathoIogy of individua1 intraperitonea1 organs, in a few cases, incIuding our own, there was no other gross pathoIogy at the time of the operation. It couId be argued that in such case the origina pathoIogy subsided and that the omenta1 mass detached itseIf from an oId Iesion. Such must have been the case in a patient of WaIther,16 in which the omenta1 tumor foI- Iowed a definite attack of appendicitis, at the time of the operation, however, the mass was free from the appendix. WaIther characterizes this situation as pathoIogy “d distance.” Pantzer is of the opinion that mere aggIutination of the omentum to an inflamed segment does not signify pathoI- ogy of the respective segment, as it may be perfectIy norma after detachment. The case of Heinrich Schoembergl’ was to a11 intent and purpose primary, and he states that “unti1 now [Igzg] an idiopathic epipIoitis has not been estabIished.” WaI- ther reported severa cases in which there was no gross pathoIogy in the peritonea1 cavity outside of the omentum.

EtioIogicaIIy speaking, then, epipIoitis foIIows, in most cases, herniotomies and abdomina1 operations, in which the omen- turn is the onIy demonstrabIe pathoIogy, or in which contamination takes pIace from an adjacent pathoIogica1 organ, such as appendix, gaI1 bIadder, intestine and, Iess frequentIy, an inflammatory process in the peIvis. ExceptionaIIy, the omentum becomes infected from without, as in the case of W. Steiger I8 in which the omentum became infected from a perforated intestine secondary to a stab wound. H. K. SowIes.19 reported a case of omenta1 abscess after a blow to the abdomen, the abscess being aggIutinated to the structures at the site of the injury. MiiIIerm described an omenta1 tumor attached to an ovarian cyst. Hadra21 reported 2 cases: one in connection with a chronic saIpingitis, the other with a perforated uterus, in which the omentum seaIed the perforation. The

New SERIES VOL. XX, No. t Schrager & Bergen-EpipIoitis ~~~~~~~~ ~~~~~~~ of surgery 47

principa1 reason for the scarcity of inffammatory tumors of the omentum in the pelvis is due to the fact that the omentaI apron is, in the majority of cases, insuffI- cientIy Iong to reach it.

The omenta1 tumor deveIops either shortIy or as Iate as two or three years after an operation. In Braun’s coIIection of 22 cases, the symptoms appeared from four weeks to three years after the patient Ieft the hospita1. BoeckeI’s22 patient deveIoped a mass three years after a herniotomy.

PathoIogicaIIy, the inffammatory changes in the omentum may be cIassified as pIastic, suppurative and chronic. The tumor mass varies in size from that of an orange to that of a fist or grapefruit; occa- sionaIIy, the entire omentum is infiItrated. Such cases were reported by Lucas Cham- pion&e and C. B. MaunseII.23 In the former case, the entire omentum was an indurated mass secondary to chronic epipIoitis in an oId inguinai hernia. The Iatter, a case of MaunseII, was a soIdier who suffered from dysentery during the WorId War and presented symptoms of subacute iIeus. At operation, the entire abdomina1 cavity was occupied by a mas- sive pIate of omentum which required bowe1 resection. The size of the mass depends upon whether or not the process is Iimited to the omentum or it takes in a neighboring organ, which augments its origina size. If it foIIows herniotomies, the mass is found in the vicinity of Poupart’s Iigament ; otherwise, it may be found in the region of the umbiIicus, ribs, and Iess commonIy in the peIvis, but prac- ticaIIy aIways in the area ‘of the origina operation.

The omenta1 pseudo-tumor is either smooth or irreguIar, doughy in consistency; it is either free or aggIutinated to some viscus or to the abdomina1 waI1. Pantzer speaks of “indefinite tumefaction.” The mass may show active signs of acute inflammation or, in about one-fourth of the cases, go on to abscess formation, usuaIIy singIe, occasionaIIy muItipIe. The acute suppurative cases may perforate spontaneousIy

into a hoIIow viscus, such as intestine, gaI1 bIadder, urinary bIadder, or even through the abdomina1 waI1. If such be the case, the discharging pus contains fragments of siIk or catgut, or omenta1 oi1, a11 of which is suggestive of its origin. In the French literature, there are a few cases reported of a persistent sinus foIIowing spontaneous rupture through the abdomina1 waI1 with siIk at the bottom of the sinus. The omenta1 mass may interfere with the func- tion of the organ to which it is aggIutinated, even to the point of obstruction. It may be so intimateIy connected with an abdomina1 organ that its detachment is technicaIIy impossibIe, without causing considerabIe anatomic damage, and it may require the extirpation of both omentum and organ en masse. SiIas Lindquist24 reported 3 cases of epipIoitis producing symptoms of ileus, a11 three requiring intestina1 surgery. In a case of Schmieden, the omenta1 mass was so intimateIy attached to the cecum and ascending coIon that resection was impossibIe; the mass was not disturbed and the obstruction was shortcircuited by anastomosing the iIeum to the transverse coIon, after which the omenta1 tumor receded.

The tumor mass may Iead a chronic existence, or, as stated, may suppurate and give rise to IocaI or genera1 peritonitis; it may perforate, and terminate in gene@ sepsis; it may bIeed, recede or compIeteIy disappear. A case of BoeckeI simuIated maIignancy, because of the presence of tumor and cachexia; uItimateIy, however, the mass disappeared without surgery. In Braun’s series, 14 out of 30 cases disappeared without operation. Whenever ep- ipIoitis is associated with pathoIogy of another organ, appendix, gaI1 bIadder, duodenum or coIon, etc., it shares the chronicity of the respective organ.

BacterioIogicaIIy, the omenta1 abscess may revea1: StaphyIococcus aIbus, strep- tococcus, coIon baciIIus, occasionaIIy tuber- cIe baciIIus and, exceptionaIIy, may show evidence of Iues. A case of Iuetic epipIoitis is reported by Armstrong Bowes,25 the

48 American Journal of Surgery Schrager & Bergen-EpipIoitis APRIL, ,933

granuIoma compressing the coIon to the point of obstruction.

The earIiest suggestion of epipIoitis is the presence of IocaIized or coIicky pain and a sense of resistance at the site of a previous operation, within two to six weeks after surgica1 interference. In the begin- ning, the condition may express itseIf in terms of Iight dyspeptic symptoms. As time goes on, the pains become severe and more Iasting and may be associated with signs and symptoms of peritonea1 irritation, such as nausea, vomiting, hiccough and meteorism. There may be paroxysms of abdomina1 pain associated with chiIIs and fever. A cIinica1 paradox is mentonedi by Prutz and Monier26: the earIier the symptoms, the more diffuse the process, the Iater, the more circumscribed the tumor. As stated, the pain is usuaIIy in the area of the origina operation, but if the mass is Iarge it may dispIace itseIf, in which case the pain moves with the tumor and may cross the median Iine and go to the other side. The tumor is, as a ruIe, mobiIe and may be dispIaced upward, side- ward, but never downward. If it is attached to the abdomina1 waI1, the mass is fixed. The tumor is not affected by respiratory movements. The percussion note over the mass is aIways duI1, since the boweIs are a1way.s behind. PhysicaI exercise may bring about pain, especiaIIy if the mass is adherent to the parieta1 peritoneum.

CASE HISTORY

Mrs. B. A., aged forty-six, married. Past History. Patient states that she has

aIways been weII, except for an attack of “bronchitis” about twenty years ago. She was then confined to bed for two months. Her physician suspected that she had puImonary tubercuIosis, but there has been no confirma- tion of this diagnosis. She has had no bronchitis since the former attack. She was never sub- jected to surgery prior to the present operation. Otherwise, the past history is essentiaIIy negative. Her menstruation was norma and ceased compIeteIy one and a haIf years ago.

Present Complaint. Two years ago, she was suddenIy seized with severe abdomina1 pains,

which were quite severe, colicky in character and were diffuse over the entire abdomen. She was taken to a hospita1 at night, where she remained for two days. The abdomina1 pains subsided after forty-eight hours, and the patient states that no definite diagnosis was made at the time. She has had since severa paroxysms of abdomina1 pains of a simiIar character at intervaIs of two or three months, Iasting one to two days. Once, she had severe pains in McBurney’s zone which was diagnosed appendicitis. At that time, she states that the right side of the abdomen “was higher than the Ieft.” She has had no chiIIs, fever, nausea or vomiting during any of these attacks. Prior to her entrance in the hospita1 under our care, she was III in bed for two days with very severe abdomina1 pains, which she characterized as “ terribIe.” She was unabIe to get out of bed; in fact, moving in bed was diffIcuIt and painfu1.

Examination. Patient was a femaIe, somewhat undernourished, rather paIe, but not acuteIy iI1. CarefuI examination of the Iungs (on- the ground of a somewhat suspicious puI- monary history of twenty years ago) reveaIed nothing abnorma1. Heart and bIood vessels were normaI. BIood pressure was 16o/g5. The abdomen was somewhat distended, abdomina1 muscIes rather fIaccid. PaIpation discIosed a diffuse, doughy mass, sIightIy movable from side to side in McBurney’s zone. It was tender to pressure, especiaIIy when pressed against the spine and posterior waI1 of the abdomen. WhiIe the mass was definiteIy palpable, its exact size could not be estimated, as it fused itseIf with other tissues. It was apparentIy not connected with the right kidney and suggested some pathoIogy in the region of the coecum. Temperature was normaI on entrance and remained so for the rest of the day. The urine was negative. BIood count reveaIed the foIIow- ing: HemogIobin, 60 per cent; white count, 8900; red count, 4,500,000. The differentia1 count was normaI.

A definite diagnosis was not estabIished, but it was quite cIear that the patient had a surgica1 abdomen which demanded expIoration. The repeated paroxysms of acute abdomina1 pains suggested an infIammatory process in the neighborhood of the coecum, possibIy appendicitis. However, the absence of temperature, nausea and vomiting spoke against it. In the absence of any viscera1 symptoms, the diagnosis of tumor did not hoId.

NEW SERIES VOL. XX, No. I Schrager & Bergen-EpipIoitis American Journal of Surgery 49

Operative Findings. A right pararectal incision was made. Upon opening the abdomen, the peritoneum was found considerably thick- ened and showed many adhesions. There was a segment of omentum adherent to the parietal peritoneum. Another segment was considerabIy in&rated forming a mass, which was attached to the ascending colon, but did not compress it. The Iatter segment was edematous, grayish and contained a tabIespoon of fouI smeIIing pus. The inflamed omenta1 mass was isolated and a resection we11 beyond the inflamed area was made. CarefuI search for a neighboring Iesion failed to discIose any gross pathoIogy. The appendix was free of adhesions, normaI in appearance and was removed as a matter of routine. The abdomen was cIosed in the usua1 manner, without drainage.

We concIuded that the patient had an acute epipIoitis, to a11 appearances primary, since there was no evidence of any other pathoIogy, either antedating or associated with the omen- ta1 infection.

The postoperative course was uneventfu1 unti1 the fifth day when she compIained of pain in the incision. At that time there was no red- ness or swelIing present. On the sixth day, there was a rise in temperature and the pain became worse. In the foIIowing four days, the temperature rose to IOI” to 102’~. and the pain was constant. On the tenth day, there appeared an eIIiptica1 mass in the incision which was tender and fluctuated. It was opened with the bIunt end of a forceps aIIowing a cup fuI1 of fou1 smeIIing pus to escape. The dis- charge continued for four weeks when it ceased.

Pathological Report. Gross: The specimen measures about 7 X 5.5 X 1.5 cm. and is roughIy irreguIar in shape. It consists of fat with a centra1 firm portion, one side of which shows an uIceration. The cut surface shows yeIIow and grayish areas. The appendix measures 5.5 X .4 cm. The serosa is pale, smooth, and gIistening. The Iumen is hardly visibIe.

the presence of a mass in the neighborhood of a previous operation, appearing from a few weeks to a coupIe of years Iater. The mass may or may not be sensitive to pressure, it is somewhat firm, doughy and may be associated with symptoms of peritonea1 irritation, viz. : nausea, vomiting, chiIIs and fever. If the mass is at or above the IeveI of the umbiIicus, it must be differentiated from pathoIogy of the appendix or gal1 bIadder, wandering Iiver, neopIasms of the spleen, tumor of the coIon; beIow the umbiIicus, from ovarian cysts, infIamma- tory masses and tumors in the peIvis. OccasionaIIy, differentiation must be made from 0mentaI Iipoma, cyst, malignancy, and tubercuIosis. In the case of a firm fixed mass in the right iIIiac fossa, one shouId excIude the possibiIity of actino- mycosis. EpipIoitis, both acute and chronic, may mimic appendicitis. H. Schoembergl’ reported 3 cases of acute hemorrhagic epipIoitis, which simuIated acute appendicitis. A painstaking inventory of symptoms, definiteIy estabIishing the sequence and order of events, wiII practicaI1y aIways make the diagnosis of appendicitis. In a number of cases, the presence of a mass associated with signs of iIeus and a Ioss of weight suggested bowel maIignancy. A rapid course with symptoms of iIeus suggested intestina1 obstruction. TeIekyz7 reported a cIinica1 compIex resembIing intestina obstruction which proved to be an omenta1 mass pressing upon the hepatic ffexure of the coIon, which disappeared upon the injection of fibroIysin.

Microscopic: Appendix: markedIy increased number of eosinophilic Ieukocytes in the mu- cosa and submucosa. Omentum: a diffuse infiItration with Ieucocytes mainIy eosinophilic, with pIasma ceIIs and Iymphocytes. In pIaces young granuIation is present.

Pathologic Diagnosis: “Subacute appendicitis; subacute omentitis.”

By way of prophyIaxis, one must avoid mass Iigation of the omentum, especiaIIy if it is acuteIy inflamed or it is gIued to the inflamed organ. The surgeon must reduce the handIing of an inflamed omen- turn to a minimum. If resection is contem- plated, one must pick up the individual bIood vesseIs and ligate them separateIy. The omentum must be divided beyond the Iine of pathoIogy we11 into the area of norma omentum.

The diagnosis of inflammatory pseudo- The prognosis of these pseudo-tumors is tumors, as aheady suggested, is made upon rather favorabIe, since a number of cases

50 American Journal of Surgery Schrager & Bergen-EpipIoitis APRIL, 1933

either disappear spontaneousIy or after rest in bed. The unfavorabIe cases may Iead to peritonitis, perforate, or go on to gen- era1 sepsis. In a case of Braun, death re- suIted from shock and hemorrhage.

The treatment shouId be conservative, somewhat aIong the Iine of the Ochsner treatment for appendicea1 abscess. If reso- Iution does not take pIace, incision and simpIe drainage shouId be done if an abscess is present. MorestirP extirpated a flap of omentum and marsupiIized the abscess cavity by suturing it into the abdomina1 wound. In the presence of marked induration with a smaI1 amount of pus, extensive resection into norma omentum must be done. If the omentum is wrapped around some abdomina1 organ from which it cannot safeIy be detached, the mass shouId be extirpated in toto, reconstructing the anatomica Ioss, either at the time of the primary operation or at some subsequent time. In a case of Schmieden, for exampIe, both omentum and gaI1 bIadder required remova en masse. Whenever the omenta1 tumor is attached to a bowe1 causing stasis or obstruction, the remova of the omenta1 mass may require either shortcircuiting or resection of the bowe1.

On the whoIe, it can be said that the treatment of omenta1 tumors ranged from the most conservative to the most daring. Many cases have improved on mere rest in bed, and ice bag to the abdomen; others have subsided spontaneousIy; some have improved greatIy on iodides; finaIIy, a great many cases required extensive surgery, either of the omenta1 mass aIone or of the mass and the surrounding organs. A smaI1 group of cases associated with 10~s

of weight and cachexia, hard to the touch and apparentIy infiItrating surrounding

structures, have defIniteIy suggested maIig- nancy and have, therefore, been deaIt with in a radica1 fashion.

By way of concIusion, it occurred to us that a detaiIed discription of omenta1 infIammatory masses may assist the cIini- can in the differentia1 diagnosis of obscure and iII-defined abdomina1 tumors, thereby being a contribution to the diagnosis of abdomina1 tumors.

1.

2.

3. 4. 5.

LUCAS CHAMPIONII?RE. Bull. et mbm. Sot. de cbir. de Paris, 24: 195, 1898.

PLAN. Diagnostic et traitement des tumeurs de1 abdomen et du bassin. Paris, 1880, 2: 448.

SCHNITZLER, J. Wien. klin. Rundscbau, p. 6, Igoo. BRAUN, H. Arch. j. klin. Cbir., 63: 378, Igor . ZESSAS, D. G. Deutscbe Ztscbr. j. Cbir., 98: 503,

1909. 6. GOLDSCHMID and SCHLOSS. Arch. j. klin. Cbir., voI.

150, 1928. 7. 8.

9. IO. II.

VAUGHAN. A. S. Warthin Anniv. VOI., 1927. BUXTON and TOREY. Med. Research, I> : E-87, Igo6. ARNAUD. Marseille mhd., 65: 765-814, 1928. J. A. M. A., go: 313, Ig. MONOD. C. Bull. et mCm. Sot. de cbir., No. 6, 18nn.

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(Absir. in Zentralbl. j. Cbir., p. Igo, 1899.) LY7- K~~TTNER. Berl. klin. Wcbnscbr., No. I, IgI3. SCHMIEDEN. Berl. klin. Wcbnscbr., 50: 908,

19’3. 14. ADAMS. Boston M. TV S. J., 180: 981, 1923.

15. PANTZER. J. A. M. A., 43: 1529, Igo4. 16. WALTHER. Bull. et mtm. Sot. de Cbir., Paris, Nr. g,

17. Sc~?&?~&. Bruns. Beitr. z. klin. Cbir., 146: 89,

1929. 18.

19.

STEIGER, W. Med. Klin., Nr. 40, 1279, 1922. SOWLES, H. K. New England J. Med., Igg: 554, _

1928. 20. 21. 22.

23.

MUELLER. Arch. j. klin. Med., 6: 146, 1876. HADRA. Ann. Surg., 14: 36, I8gI. BOECKEL. Rev. de GynLc., I : 479, 1897. MAUNSELL, C. B. Irish J. Med. SC., 13-24: 674,

1927. 24.

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LINDQUIST, S. Acta Cbir. Scandinav., 54: gr-Ioo,

Bo%~-“A: Brit. M. J., p. 628, 1898. PRUTZ Hnd MONIER,. Deutscbe Cbir., 46: K-1913. TELEKY. Wien. klin. Wcbnscbr., 20: 237, 1907. MORESTIN. Gaz. d. Hdp., Nr. 135 and 136, Igoo.

REFERENCES

primary acute epiploitis

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