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ABDOMINAL IMAGING Table of Contents   
Year : 2003  |  Volume : 13  |  Issue : 4  |  Page : 413-414
Omental tuberculosis


Radiodiagnosis Deptt., IG Medical College, Shimla- 171 001(H.P), India

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Keywords: Tuberculosis, Omemtum, USG, CT

How to cite this article:
Dhiman D S, Goyal D, Prakash S, Negi A, Sharma S. Omental tuberculosis. Indian J Radiol Imaging 2003;13:413-4

How to cite this URL:
Dhiman D S, Goyal D, Prakash S, Negi A, Sharma S. Omental tuberculosis. Indian J Radiol Imaging [serial online] 2003 [cited 2019 Sep 21];13:413-4. Available from: http://www.ijri.org/text.asp?2003/13/4/413/28722
Tuberculosis is'very common in our country, common sites of involvement being lungs, intestines, bones and genito-urinary system etc. Tuberculosis of omentum is a rare entity and very few cases have been reported in the literature. Omental tuberculosis occurs as a part of tuberculous peritonitis termed as "fibrotic-fixed" type [1]. An omental mass is formed which can be demonstrated on US; however, it maybe difficult to distinguish the same from the intestine or anterior abdominal wall mass [2]. We are presenting here a case of omental tuberculosis in a fifty-years old man.


   Case Report: Top


A fifty-years old man presented with complaints of pain and lump abdomen for two months. There was history of constipation, loss of appetite and weight loss for the same duration, but there was no history of blood in the stools. On clinical examination of abdomen, there was a lump of approx. 12x10cm extending from the left hypochondrium to the umbilical region; margins of the mass were irregular and it was tender. Clinical impression was growth splenic flexure of colon.

US examination of the abdomen on RT-3200 revealed a heterogenous mass in left hypochondrium and lumbar region involving the gut as well as the anterior abdominal wall [Figure - 1],[Figure - 2]. Liver, spleen, kidneys and pancreas were normal. There was no abdominal lymphadenopathy or ascites. On US a probability of a mass arising from either the intestine or anterior abdominal wall was kept.

CT abdomen revealed a heterogeneous soft tissue density mass of 10x15cm size. It was between the transverse colon and anterior abdominal wall and adherent to them. [Figure - 3],[Figure - 4]. It was thought to be an omental mass and possibility of omental tuberculosis was kept. FNAC from the mass was inconclusive. Exploratory laparotomy confirmed an omental mass which was adherent to the small intestine and the parietal peritoneum. Interloop adhesions were also present and the mesentery was thickened. Imprint smear and biopsy of the mass confirmed it to be tuberculosis of the omentum.


   Discussion: Top


Tubercular peritonitis presents in three different types as (a) "wet-ascitic", (b) "fibrotic-fixed" and (c) "dry-plastic" type [3]. The "wet-ascitic" type is observed in 90% of the patients and is characterized by the presence of free or loculated ascitic fluid. The "fibrotic-fixed" type is less common, features of which are omental involvement, matted and tethered bowel loops and mesentery and sometimes loculated-ascites. The "dry-plastic" type is unusual type characterized by caseous nodules, fibrotic peritoneal reaction and dense adhesions [3].

Omental involvement as part of "fibrotic-fixed" type of tubercular peritonitis is seen as an irregular mass due to infiltration of omentum by tubercular lesions [4]. The involvement has been classified as "nodular", "smudge" or "caked" appearances [3]. On US the omental mass is seen as hyperechogenic mass anterior to the bowelloops; it may be difficult to distinguish the mass from intestine and anterior abdominal wall [2]. Although omentum is situated in front of bowel gas and mesenteric fat, US detection of omental involvement is poor, reported in only 14-55% of cases in different series [2],[5],[6]. Omental pathology is better seen on CT i.e. 36-82% patients in different series [2],[3],[7],[8]. CT patterns of omental tuberculosis consist of solid masses (omental-cakes), nodular and smudge pattern. Smudge type is the most common type demonstrated by CT. Omentum is frequently involved in both peritoneal-tuberculosis and peritoneal-carcinomatosis; most useful distinguishing CT findings are smooth parietal peritoneum with minimal thickening and pronounced enhancement in peritoneal tuberculosis, whereas nodular implants and irregular peritoneal thickening suggest peritoneal carcinomatosis [5]. The diagnosis still requires a high index of suspicion, once the suggestive features have been demonstrated by imaging modalities.

 
   References Top

1.Jadvar H, Mindelzun RE, Olcott EW, Levitt DB, Still the great mimicker: abdominal tuberculosis. AJR 1997 Jun; 168(6): 1455-60.Erratum in: AJR 1997 Aug; 169(2): 602.  Back to cited text no. 1    
2.Demirkazik FB, Akhan 0, Ozmen MN, Akata D, US and CT findings in the diagnosis of tuberculous peritonitis. Acta Radiol. 1996 Jul; 37(4): 517-520.  Back to cited text no. 2    
3.Akhan 0, Pringot J. Imaging of abdominal tuberculosis, Eur Radiol. 2002 Feb; 12(2): 312-23.  Back to cited text no. 3    
4.Sheikh M, Mossa I, Hussein FM, Qurttom MA, Behbehani Al, Ultrasonic diagnosis in abdominal tuberculosis. Australas Radiol. 1999.May; 43(2): 175-9.  Back to cited text no. 4    
5.Lee DH, Lim JH, Ko YT, Yoon Y, Sonographic findings in tuberculous peritonitis of wet-ascitic type. Clin Radiol. 1991; 44: 306-310.  Back to cited text no. 5    
6.Ramaiya LI, Walter DF, Walter R, Sonographic features of tuberculous peritonitis. Abdom Imaging. 1993; 18: 23-26.  Back to cited text no. 6    
7.Rodriguez E, Pombo F, Peritoneal tuberculosis versus peritoneal carcinomatosis: distinction based on CT findings. J Comput Assist Tomogr. 1996 Mar-Apr; 20(2): 269-72.  Back to cited text no. 7    
8.Ha HK, Jung JI, Lee MS, CT differentiation of tuberculous peritonitis and peritoneal carcinomatosis. AJR. 1996; 167: 743-748.  Back to cited text no. 8  [PUBMED]  [FULLTEXT]

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Correspondence Address:
D S Dhiman
Valley View, Dhingu Road, Sanjauli, Shimla. 171 006(H.P)
India
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  [Figure - 1], [Figure - 2], [Figure - 3], [Figure - 4]



 

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