Gray-scale and color Doppler sonographic diagnosis of epiploic appendagitis

Epiploic Appendagitis Mimicking Acute Appendicitis: An Osteopathic Case Report

Acute epiploic appendagitis is a rare cause of abdominal pain, often misdiagnosed as acute appendicitis or diverticulitis given similar clinical presentation and findings. The treatment is supportive care and is typically self-limited. The osteopathic structural exam can give insight into pathology and in this case, was suggestive of a non-appendiceal origin of her pain, in which emergent surgery could be avoided. Requiring computerized tomography to identify, acute epiploic appendagitis is a rare cause of abdominal pain and should be considered in the differential diagnosis.

Epiploic appendagitis: pathogenesis, clinical findings and imaging clues of a misdiagnosed mimicker

Primary epiploic appendagitis (PEA) is a rare and frequently underdiagnosed cause of acute abdominal pain. PEA most commonly affects obese, male patients in the 4th and 5th decade of life. Clinical presentation includes acute, localized, non-migrating pain without fever, nausea, vomiting or diarrhea and the laboratory workup is usually within normal limits. PEA is commonly mistaken as other more severe causes of acute abdominal pain, such as diverticulitis, acute appendicitis or cholecystitis and thus patients undergo unnecessary diagnostic and therapeutic procedures. The emergence of computerized tomography (CT) as the gold standard imaging test in diagnostic dilemmas of acute abdominal pain has resulted in increased recognition and diagnosis of PEA. Upon confirmation, PEA is considered a self-limiting disease and is managed conservatively with analgesics, occasionally combined with nonsteroidal anti-inflammatory drugs (NSAIDS). Persistence of symptoms or recurrence mandate the consideration of surgical management with laparoscopic appendage excision as the definitive treatment. We review the current literature of PEA, with a focus on clinical and imaging findings, in order to raise awareness about this frequently misdiagnosed entity.

[A rare and unrecognized cause of abdominal pain: epiploic appendagitis: about a case]

Les appendagites épiploïques primitives sont des causes rares d’abdomen aigu. Elles sont souvent prises pour une appendicite aiguë ou une sigmoïdite diverticulaire et le diagnostic est posé au cours d’une intervention chirurgicale. Nous rapportons un cas où la tomodensitométrie a permis de poser le diagnostic et nous insisterons sur l’aspect imagerie qui permet de sursoir ainsi à une chirurgie inutile.

Epiploic Appendagitis Mimicking Recurrent Diverticulitis

Here, we report a case in which a patient with an extensive history of diverticulitis of the sigmoid colon presented with left lower quadrant abdominal pain similar to her previous episodes of diverticulitis. An initial diagnosis of diverticulitis was made based on her history and exam, intravenous antibiotics were given, and an elective surgical resection was considered. However, a subsequent CT scan revealed epiploic appendagitis with no evidence of diverticulitis. Though uncommon, in patients with a history of recurrent diverticulitis, alternative causes of left lower quadrant abdominal pain such as epiploic appendagitis should be considered as this may alter future treatment decisions.

[Primitive omental appendagitis: a rare cause of abdominal pain]

Les appendagites sont une cause rare de douleur abdominale chez l'adulte, elles simulent souvent le tableau d'une appendicite aiguë ou une sigmoïdite, le diagnostic est souvent poser par une TDM ou lors d'un acte chirurgicale, le traitement est essentiellement médicale.

[Contribution of imaging in the diagnosis of epiploic appendagitis]

INTRODUCTION

Primary epiploic appendagitis is known to be a rare finding among causes of acute abdomen. Depending on location, it may mimic several disorders such as colonic diverticulitis and acute appendicitis. Diagnosis is sometimes performed during surgery.

METHODS

This is a retrospective descriptive study. The authors report the contribution of imaging for the diagnosis of appendagitis in seven patients investigated between July 2010 and April 2013 by abdominal and pelvic ultrasound or computed tomography (CT).

RESULTS

CT scan confirmed the diagnosis in six patients avoiding unnecessary surgery and hospitalization. The seventh patient was a pregnant woman in whom the diagnosis of appendagitis was made during surgery for appendicitis.

CONCLUSION

Appendagitis is a rare cause of acute abdominal pain. Outcome is favorable with medical treatment only. Abdominal ultrasound and CT are helpful diagnostic tests avoiding useless surgical procedure.

Epiploic appendagitis: is there need for surgery to confirm diagnosis in spite of clinical and radiological findings?

BACKGROUND

The present retrospective study was conducted to review the authors' experience and describe clinical and radiologic features of epiploic appendagitis (EA), which is an uncommon, self-limiting clinical entity mimicking acute appendicitis and diverticulitis. Awareness of the features of EA would allow a correct diagnosis and avoid unnecessary surgical interventions.

METHODS

Patients diagnosed as EA in one regional medical center between June 2006 and June 2010 were included. Clinical, laboratory, and imaging features of EA were studied, with particular attention to its unique radiologic appearances.

RESULTS

Twenty patients (13 men and 7 women; average age 43.2 years) diagnosed with EA were included in the study. Localized abdominal pain without nausea, vomiting, and fever were the major presenting symptoms for all patients. Laboratory blood tests were normal, except in one patient with leukocytosis and two patients with increased serum C-reactive protein (CRP) levels. A noncompressible hyperechoic ovoid mass with hypoechoic border and without central blood flow on Doppler ultrasound (US) was detected in five of six patients. In all patients, the computed tomography (CT) scans revealed an ovoid fatty mass with hyperattenuating rim and disproportionate adjacent fat stranding. Central dot sign, concomitant old infarct, and lobulation were present in 75%, 20%, and 10% of the patients, respectively. All of the patients were treated conservatively. No recurrences occurred during the follow-up period (average: 24.8 months) in 18 (90%) of the patients.

CONCLUSIONS

In patients with localized abdominal pain without other symptoms, diagnosis of EA should be considered. Recognizing the US and CT features of EA may allow an accurate diagnosis and avoid unnecessary surgery.

Intraabdominal focal fat infarction in a 75-year-old woman presenting as acute abdomen

Epiploic appendagitis is a rare, self-limiting inflammation of the epiploic appendices or omental appendices. It presents as abdominal pain often misdiagnosed as appendicitis, cholecystitis, or diverticulitis. Epiploic appendagitis can be treated conservatively with anti-inflammatory and pain medications. It is important to diagnose this etiology of abdominal pain in order to avoid long-term hospital stay and other medical expenses including surgery. In this case report we present a rare case of epiploic appendagitis that presents in a 75 year old female patient.

Insights into epiploic appendagitis

Epiploic appendagitis is a rare cause of abdominal pain. Diagnosis of epiploic appendagitis, although infrequent, is easily made with CT or ultrasonography in experienced hands. As reported in the literature, most patients with primary epiploic appendagitis are treated conservatively without surgery, with or without anti-inflammatory drugs. A small number of patients are treated with antibiotics and some patients require surgical intervention to ensure therapeutic success. Symptoms of primary epiploic appendagitis usually resolve with or without treatment within a few days. A correct diagnosis of epiploic appendagitis with imaging procedures enables conservative and successful outpatient management of the condition and avoids unnecessary surgical intervention and associated additional health-care costs. Gastroenterologists and all medical personnel should be aware of this rare disease, which mimics many other intra-abdominal acute and subacute conditions, such as diverticulitis, cholecystitis and appendicitis. This article reviews epiploic appendagitis and includes discussion of clinical findings, pathophysiology, diagnosis and therapeutic possibilities.

Inflammatory fatty masses of the abdomen

While omental infarction (OI) and acute epiploic appendagitis (AEA) often clinically mimic surgical abdomen, their management is distinct. As such, accurate and timely diagnosis is essential to follow medical management. Computed tomography and ultrasound imaging, utilized routinely in the evaluation of acute abdominal pain in the emergent setting, facilitate diagnosis and appropriate management of OI and AEA. The awareness of the clinical manifestations and imaging features of OI, AEA, and their mimics allow the radiologist to play a decisive role in triaging patients into surgical and medical management groups.

Epiploic appendicitis in inguinal hernia sac presenting an inguinal mass

Inguinal hernia sometimes surprises surgeons with its unexpected content. Epiploic appendagitis in hernia sac is a very rare entity. We report a 60-year-old male patient with a painless inguinal mass. Surgical exploration showed a 4-cm mass beneath the external oblique aponeurosis that consisted of a hernia sac containing an inflamed and remarkably swollen appendix epiploica of the sigmoid colon secondary to torsion. The patient recovered after the resection of epiploic appendix and a tension-free hernia repair.

CT appearance of acute appendagitis

OBJECTIVE

Our aim was to describe the spectrum of CT findings in patients with acute epiploic appendagitis and also to evaluate the changes seen with this condition.

MATERIALS AND METHODS

Fifty patients diagnosed with acute epiploic appendagitis seen on contrast-enhanced CT were included in this study. The CT scans of the epiploic appendagitis were evaluated for the presence of colon wall thickening, a focal fatty center, inflammatory changes, location in relationship to the colon, size, and presence or absence of central high density within the fat. In 10 patients, the initial findings were compared with findings of follow-up CT performed between 3 days-21 months after the first CT.

RESULTS

The most common part of colon involved by acute epiploic appendagitis was the sigmoid colon (31/50), and the most common position was anterior to the colonic lumen (41/50). All 50 patients with acute epiploic appendagitis had a central fatty core surrounded by inflammation. Colon wall thickening was present in only two, and a central high-density focus was noted only in 27 of 50 patients. In 86% (43/50) of patients, the fatty central core was between 1.5 and 3.5 cm in length. The changes seen on follow-up CT varied, including increased density with a decrease in the size of the fatty central core, no change, complete resolution of findings, and minimal residual density.

CONCLUSION

On CT, acute epiploic appendagitis has a predictable appearance in terms of location, size, and density. The most common finding on CT is a fat-density oval lesion with surrounding inflammation on the anterior aspect of the sigmoid colon. The changes on CT are not predictable in the 2-week to 6-month window.