Radiology of epiploic appendages: acute appendagitis, post-infarcted appendages, and imaging natural history

Epiploic appendagitis: a commonly undiagnosed non-surgical acute abdominal emergency

Epiploic appendagitis is a rare cause of acute abdomen and is diagnostically challenging as it mimics common causes of acute abdomen. However, advancements in computerised tomography/Ultrasound imaging have improved the frequency and confidence of diagnosing epiploic appendagitis, preventing unnecessary surgeries. We present a case of an acute abdomen who had to undergo laparoscopy before being diagnosed with epiploic appendagitis, underscoring the difficulty in diagnosis.

[Incidental and "leave me alone" findings of the GI tract-part 2 : Intestinal wall and mesentery]

Due to the widespread use of computed tomography (CT) and magnetic resonance imaging (MRI) asymptomatic incidental findings of the gastrointestinal (GI) tract are increasingly being recognized. Incidental findings are frequently not part of the primary inquiry from referring physicians but it is obligatory to make a diagnosis and to stipulate the need for further clarification. A multitude of incidental findings in the intestinal lumen, in the intestinal wall and in the adjacent mesentery or subperitoneal space are shown in CT and MRI of the GI tract. The last part of the two-part review addresses the gastrointestinal incidental findings in the intestinal wall and the adjacent sections. Extramural incidental findings occur as mesenteric inflammation, tumors and cysts. Many of the findings can be classified as benign and as "leave me alone lesions" do not necessitate any further clarification but in contrast others need a definitive clarification. The most important incidental findings in the GI tract are systematically classified, illustrated and evaluated with respect to the clinical relevance, depending on the localization (e.g. stomach, small and large intestines).

Bowel ultrasonography in acute abdomen: beyond acute appendicitis

Acute abdomen is a common reason for consultation in the emergency department. A broad spectrum of entities, including diverse diseases of the gastrointestinal tract, can cause acute abdomen. Although computed tomography is the technique most widely used to evaluate acute abdomen in the emergency department, abdominal ultrasound is often performed first and allows bowel disease to be suspected. This article describes the ultrasound features of diverse bowel diseases that can cause acute abdomen, such as acute diverticulitis, bowel obstruction, gastrointestinal perforation, bowel ischemia, intraabdominal fat necrosis, and miscellaneous processes such as endometriosis, foreign bodies, or vasculitis. Radiologists must be familiar with the different features of abnormal bowel that can be detected incidentally in patients without clinical suspicion of bowel disease. This article focuses on ultrasonographic signs of bowel disease; other articles in this series cover the ultrasonographic signs of acute appendicitis, inflammatory bowel disease, and infectious diseases.

MR Imaging of the Perihepatic Space

The perihepatic space is frequently involved in a spectrum of diseases, including intrahepatic lesions extending to the liver capsule and disease conditions involving adjacent organs extending to the perihepatic space or spreading thanks to the communication from intraperitoneal or extraperitoneal sites through the hepatic ligaments. Lesions resulting from the dissemination of peritoneal processes may also affect the perihepatic space. Here we discuss how to assess the perihepatic origin of a lesion and describe the magnetic resonance imaging (MRI) features of normal structures and fluids that may be abnormally located in the perihepatic space. We then review and illustrate the MRI findings present in cases of perihepatic infectious, tumor-related, and miscellaneous conditions. Finally, we highlight the value of MRI over computed tomography.

Intraperitoneal focal fat infarction: the great mimicker in the acute setting

The term intraperitoneal focal fat infarction (IFFI) includes various self-limiting clinical conditions that are caused by focal fatty tissue necrosis. Most of the cases of IFFI concern torsion or infarction of the greater omentum or the epiploic appendages. However, although rarely, perigastric ligaments can also undergo torsion also leading to fat infarction. IFFI clinically may mimic other pathologies, such as acute appendicitis or diverticulitis, making their clinical diagnosis a challenge. Ultrasound (US) and computed tomography (CT) have a high sensitivity and specificity for the diagnosis of IFFI excluding other pathologies, and in most cases, the clinical evolution is spontaneously favorable, thus helping to reduce the need for unnecessary surgical intervention. We review cases with IFFI in order to identify specific involvement patterns. Cases of epiploic appendages reported to an acute, subacute, and more chronic phase in order to present the self-limiting nature of this entity and the resultant absorption. We also present cases with falciform ligament infarction, as well as primary ("whirl sign" on CT due to greater omentum torsion) and secondary omental infarctions. The aim of this pictorial review is not only to extensively explore the imaging findings of IFFI but to also describe the clinical presentation and pathophysiology of the prementioned conditions.

Peritoneal loose bodies and the differentiation of fatty abdominal and pelvic lesions

Peritoneal loose bodies (PLBs) have been sparingly documented within the surgical and radiologic literature, with 38 cases reported to date. A 67-year-old male presented to urology for the management of an asymmetric prostatic nodule. Imaging incidentally identified a well-circumscribed mass of low T2 signal intensity with a small fatty core in the left lower quadrant close to the sigmoid colon; malignancy was in the differential. The mass grew slightly over the next year. A diagnostic laparoscopy retrieved a free floating 4 × 4 cm benign mass from the pelvis, identified as necrotic fat with areas of dystrophic calcifications. PLBs are often a diagnostic dilemma without surgical intervention. Here we present a diagnostic algorithm based on a comprehensive literature review and our case to help better identify unknown abdominal and pelvic fatty masses and to avoid surgery strictly for diagnosis, especially for patients that are not ideal surgical candidates. Using this algorithm, the mass in the patient presented here could have been accurately characterized without invasive diagnostic measures.

Acute epiploic appendagitis: ultrasound and computed tomography findings of a rare case of acute abdominal pain and the role of other imaging techniques

Purpose

Acute epiploic appendagitis (EA) is a relatively rare, benign and local inflammatory disease involving the epiploic appendices. Unlike its mimics, EA is generally a self-limiting inflammatory disease and can be treated conservatively.

Case presentation

A 33-year-old Caucasian man presented to our emergency department with a sever and sharp left iliac fossa pain. He underwent abdominal X-ray, ultrasound (US) and computed tomography (CT) evaluations.

Conclusion

We illustrate US and CT findings to increase the radiologists’ awareness of this condition and to avoid diagnostic delay and unnecessary use of antibiotics, hospitalization and surgery.

Acute epiploic appendagitis at the tip of the appendix mimicking acute appendicitis: A rare case report with literature review

BACKGROUND

Acute epiploic appendagitis of the appendix (AEAA) is a rare self-limiting inflammatory disorder of the epiploic appendages (EA) close to the vermiform appendix, which often times mimicking the presentation of acute appendicitis (AA). To date, very few cases of AEAA have been reported. We report a case of a 52-year old man with the clinical suspicion of AA, but post-operative specimen examination confirmed AEAA as the final diagnosis.

CASE SUMMARY

A 52-year-old morbidly obese man presented to the emergency department with a 1-d history of the right lower quadrant (RLQ) abdominal pain. Physical examination revealed localized RLQ tenderness mimicking AA. The computed tomography abdomen was inconclusive, and a decision was made to perform laparoscopic appendectomy (LA). During the LA, an infarcted epiploic appendage at the tip of appendix and adherent to the abdominal wall was found, which was entirely excised. Final pathology showed congested and hemorrhagic epiploic appendage without any accompanied acute inflammatory changes in the wall of the appendix. Postoperative course was uneventful and he was doing well at seven months follow-up.

CONCLUSION

The possibility of AEAA should be considered in patients clinically suspected of having AA. Surgery is considered for those refractory to conservative management, with inconclusive diagnosis or develop complications at presentation.

Acute Epiploic Appendagitis: A Nonsurgical Abdominal Pain

Epiploic appendagitis is a relatively rare disease characterized by an inflammation of fat-filled serosal outpouchings of the large intestine, called epiploic appendices. Diagnosis of epiploic appendagitis is made challenging by the lack of pathognomonic clinical features and should therefore be considered as a potential diagnosis by exclusion first of all with appendicitis or diverticulitis which are the most important causes of lower abdominal pain. Currently, with the increasing use of ultrasound and computed tomography in the evaluation of acute abdominal pain, epiploic appendagitis can be diagnosed by characteristic diagnostic imaging features. We present a case of epiploic appendagitis with objective of increasing knowledge of this disease and its diagnostic imaging findings, in order to reduce harmful and unnecessary surgical interventions.

CT imaging findings of epiploic appendagitis: an unusual cause of abdominal pain

Epiploic appendagitis is a rare cause of acute abdominal pain, determined by a benign self-limiting inflammation of the epiploic appendages. It may manifest with heterogeneous clinical presentations, mimicking other more severe entities responsible of acute abdominal pain, such as acute diverticulitis or appendicitis. Given its importance as clinical mimicker, imaging plays a crucial role to avoid inaccurate diagnosis that may lead to unnecessary hospitalization, antibiotic therapy, and surgery. CT represents the gold standard technique for the evaluation of patients with indeterminate acute abdominal pain. Imaging findings include the presence of an oval lesion with fat-attenuation surrounded by a thin hyperdense rim on CT (“hyperattenuating ring sign”) abutting anteriorly the large bowel, usually associated with inflammation of the adjacent mesentery. A central high-attenuation focus within the fatty lesion (“central dot sign”) can sometimes be observed and is indicative of a central thrombosed vein within the inflamed epiploic appendage. Rarely, epiploic appendagitis may be located within a hernia sac or attached to the vermiform appendix. Chronically infarcted epiploic appendage may detach, appearing as an intraperitoneal loose calcified body in the abdominal cavity. In this review, we aim to provide an overview of the clinical presentation and key imaging features that may help the radiologist to make an accurate diagnosis and guide the clinical management of those patients.

Epiploic appendagitis: 7-year experience and relationship with visceral obesity

PURPOSE

Location, size, and local inflammatory findings in primary epiploic appendagitis (EA) have not been reported outside of small studies. The association between EA and increased adiposity is controversial. The goals of this project are to compare demographics and imaging-based measurements of adiposity between patients with EA and patients with acute abdomen without EA, and to identify CT features of EA.

METHODS

A consecutive sample of acute, primary EA (n = 100), and control (acute abdomen; n = 100) was selected retrospectively. Cases of suspected EA were included if they had the characteristic ovoid fatty mass and hyperattenuated ring sign on CT. Abdominal adipose volume (AAV), visceral adipose area (VAA), and subcutaneous adipose area (SAA) were quantified by CT. Location, size, and frequency of coexisting local inflammatory findings in EA patients were recorded.

RESULTS

EA had 60% greater AAV, 117% greater VAA, and 35% greater SAA than control subjects (p < 0.0001). Males composed a great proportion of the EA group (67%) than the control group (41%) (p = 0.0002). Inflamed appendage was found in sigmoid colon in 49% of cases, descending colon in 23%, and right colon in 19%. Peritoneal thickening was frequent (76%) and bowel wall thickening was common (47%). Diverticulosis coexisted incidentally in 28%.

CONCLUSION

EA is associated with increased abdominal adipose tissue. EA can occur in both sexes at any age, but occurs at age 50 on average and more frequently in males. Patient with EA exhibited central hyperdense dot (79%), peritoneal thickening (76%), and bowel wall thickening (47%).

Auto-amputated adnexa in a young woman: Multimodal imaging to rule in a pelvic rolling stone

We report the case of a 26-year-old woman with a right auto-amputated adnexa and a free-floating mass in the pouch of Douglas using multimodal imaging studies including ultrasonography, computed tomography, and magnetic resonance imaging. The absence of an ovary and the evidence of an amorphous and potentially calcified mass, with no connection to the genital tract - in particular when it is found to be mobile - are the key imaging findings. Prospective diagnosis of adnexal auto-amputation could assist surgeons in patient management with a curative laparoscopy in symptomatic women, or potentially expectant management in young women who are asymptomatic or have unrelated symptoms.

Epiploic appendagitis: A rare cause of acute abdomen

Epiploic appendagitis is a rare cause of acute abdomen that often manifests with acute onset of pain in the left or right lower quadrant. Its symptoms can mimic and be mistaken for acute diverticulitis, appendicitis, or omental infarction. In this case report, we discuss a 65-year-old woman who presented with sharp right upper and lower quadrant abdominal pain, for which she had an emergent abdominal computed tomography (CT) scan. On CT images, epiploic appendagitis will appear as oval lesions with a central area of fat attenuation, accompanied by surrounding inflammation. Ultrasound and magnetic resonance imaging are more often used to evaluate acute abdominal pain in the pediatric and obstetric populations, so the respective findings of acute epiploic appendagitis must be recognized in those examinations as well. Despite the rarity of the condition and its common omission from differential diagnoses, the ability to recognize and diagnose epiploic appendagitis from its imaging is important for radiologists, especially considering its potential complications. If not diagnosed correctly, epiploic appendagitis can result in unnecessary hospital admission and patient workup, antibiotic use, dietary restrictions, and perhaps even unnecessary surgery. In this case, the diagnosis of epiploic appendagitis using CT allowed the patient to avoid surgery and other invasive treatment, and the patient was eventually discharged on conservative medical management.

Thoracolithiasis-Computed Tomography Findings of Intrapleural Loose Bodies

Thoracoliths are rare benign intrapleural loose bodies, often containing calcification, that are mobile in the pleural cavity. The presence of these intrapleural nodules is referred to as thoracolithiasis. The exact etiology of thoracoliths is unknown, but they presumably result from a prior episode of mediastinal (epipericardial) fat necrosis. Thoracoliths are usually asymptomatic and incidentally encountered on computed tomography. However, they sometimes pose diagnostic challenges, as a thoracolith may be located within a pleural fissure, and is then indistinguishable from a pulmonary nodule. In addition, migration and rotation of thoracoliths within the pleural space observed on serial computed tomography studies has been reported to raise concern that these might be neoplastic lesions, leading to their surgical removal. Awareness of this benign condition is important in order to avoid unnecessary invasive procedures.