Insights into epiploic appendagitis

A Rare Presentation of Epiploic Appendagitis as Chest Pain: A Case Report

Epiploic appendagitis (EA) is an ischemic infarction of an epiploic appendage due to torsion or spontaneous thrombosis of the central vein of an epiploic appendage. It is a rare but benign and self-limiting cause of abdominal pain that is often misdiagnosed. The typical presentation of EA is lower abdominal pain, but pain can also occur in other parts of the abdomen. Presentation outside of the abdomen is a rare occurrence. Our patient presented with chest pain, and it was only through physical examination that mild right upper quadrant tenderness led to the suspicion of an intra-abdominal pathology, which was then confirmed with imaging. The patient responded to conservative management. Our possible explanation for this occurrence includes the proximity of the inflamed appendage to organs associated with chest pain and the possibility that patients sometimes describe pain location inaccurately.

Epiploic Appendagitis Unveiled: A Case of Misleading Abdominal Pain With Omental Fat Necrosis

Epiploic appendagitis is a benign inflammatory condition of the epiploic appendages, small fat-filled structures attached to the colon. Misdiagnosed frequently as more serious conditions like appendicitis or diverticulitis, it usually resolves with minimal treatment. This case report aims to emphasize the importance of recognizing epiploic appendagitis in differential diagnoses, highlighting the role of accurate imaging and surgical intervention in managing unusual presentations. We report a case involving a 27-year-old male who presented with acute, severe pain in the left iliac fossa. Initial assessments showed stable vital signs and negative virology screenings. Ultrasound imaging did not reveal any abnormalities in the abdominal organs but noted multiple gas-filled bowel loops and a 48 x 22 mm collection in the left iliac region. A CT scan with IV contrast further identified a 35 x 26 mm area of fat stranding in the left iliac fossa, indicative of epiploic appendagitis, and a 1 cm area of omental fat necrosis near the hepatic flexure. Persistent symptoms led to a diagnostic laparoscopy, which confirmed and treated gangrenous appendices epiploica. The patient's postoperative recovery was uneventful, highlighting the effectiveness of surgical management. This case underscores the necessity for heightened awareness and diagnostic precision when encountering patients with acute abdominal pain that does not match common ailments. Early and accurate imaging, followed by timely surgical intervention if needed, can significantly improve outcomes by preventing complications from misdiagnosis or delayed treatment.

Uncommon Etiologies of Acute Abdominal Pain: A Case Report on Omental Infarction

Omental infarction is an uncommon cause of abdominal pain. The condition is often misdiagnosed due to its clinical similarity to more common abdominal pathologies like appendicitis and cholecystitis. This report presents the case of a 57-year-old female with a one-week history of left-sided abdominal pain, initially aggravated by eating and defecation. The patient, a long-term smoker with a complex medical history that includes deep vein thrombosis and pulmonary embolism, was hemodynamically stable on presentation. A CT scan revealed a nodular infiltration consistent with an omental infarct. Conservative management was pursued, resulting in symptom resolution by the third day of hospitalization. This case underscores the diagnostic challenges associated with omental infarction, particularly its differentiation from other causes of acute abdominal pain. It highlights the importance of considering rare etiologies in patients with atypical presentations and emphasizes the role of imaging, particularly CT scans, in accurate diagnosis. The patient's successful conservative management aligns with current recommendations, which advocate for non-surgical treatment in most cases. This approach avoids unnecessary surgical interventions and ensures a favorable prognosis with low complication rates in patients with prompt and appropriate management.

Diagnosis and treatment of epiploic appendagitis in a Middle Eastern country: An observational retrospective analysis of 156 cases

BACKGROUND

Epiploic appendagitis (EPA) is an uncommon emergency surgical condition that causes acute abdominal pain, rendering a list of differential diagnoses. Therefore, careful examination and imaging tools are required. EPA is a self-limiting condition that can be resolved in 1-2 weeks and rarely needs surgical intervention. Its low incidence makes EPA less well-known among the public and some medical professionals, and it is frequently under-diagnosed. We aimed to explore the incidence, clinical presentation, modalities of imaging to diagnose and options for treating EPA.

METHODS

An observational retrospective analysis was conducted between 2016 and 2022 at a tertiary hospital in an Arab Middle Eastern country.

RESULTS

There were 156 EPA cases diagnosed over six years, with a mean age of 33 years. Males represented 82% of the cohort. The entire cohort was treated non-operatively except for eight patients who had surgical intervention using open or laparoscopic surgery. The diagnosis was made by a computerized tomographic scan (CT). However, plain X-ray, abdominal ultrasound, and magnetic resonance imaging (MRI) were performed initially in a few selected cases to rule out other conditions. No specific blood test indicated EPA; however, a histopathology examination was diagnostic. No mortality was reported in the study cohort.

CONCLUSION

This is the most extensive study analyzing EPA patients from the Middle East. EPA is a rare and mostly self-limiting acute abdominal disorder; however, early ultrasound and CT scan can pick it up quickly after a high index of suspicion.

Prevalence of SIRS with primary epiploic appendagitis

PURPOSE

Primary epiploic appendagitis (PEA) is not an uncommon cause of abdominal pain. The systemic inflammatory response syndrome (SIRS) criteria have high sensitivity for early detection of inflammation and infection. To date, there is limited data about the association between SIRS and PEA. The aims of this retrospective study were to evaluate the prevalence of SIRS response and its clinical relevance in patients diagnosed with PEA within a large tertiary hospital network.

METHODS

A retrospective study was performed on all consecutive adult patients who presented to four major emergency departments with CT-confirmed PEA from 01 January 2022 to 27 March 2023. The fulfilment of SIRS criteria, hospital admission rate and treatments provided were analysed for these patients.

RESULTS

Seventy-three patients had CT-confirmed PEA. Seventeen patients (23.2%) with PEA were SIRS positive. The hospital admission rate in the SIRS group trended higher than the non-SIRS group (odds ratio of 2.51, 95% CI (0.75, 8.39)). The odds of having an associated radiological comorbidity unrelated to PEA were 18.7 times higher in the SIRS positive group. Fifty-seven (78%) patients were discharged home, and 16 (22%) patients were admitted into hospital. Nearly all patients were treated conservatively (98.6%).

CONCLUSION

PEA patients with SIRS response trend towards a higher hospital admission rate and are significantly more likely to have other radiological comorbidities than non-SIRS patients. It is important to look for other pathological conditions in a SIRS positive patient with a CT-diagnosis of PEA.

Uncommon presentation of complicated internal hernia through the appendices epiploicae ring of adhesion: a clinical case study

Background

Internal hernias are infrequent, yet serious, medical conditions with potentially severe consequences. An internal hernia resulting from an Appendices epiploicae (AE) ring is an especially rare cause, with a mere nine documented instances worldwide.

Case report

This report presents the case of a 58-year-old male who suffered from an internal hernia originating from an AE ring. The condition led to a gangrenous small bowel, which was treated by laparotomy and resection of the affected segment, followed by primary anastomosis. The post-operative recovery was favorable.

Conclusion

Internal hernias, although rare, warrant immediate attention and early intervention to preclude detrimental outcomes, as illustrated in this particular case.

[Epiploic appendagitis: an uncommon and nonsurgical cause of abdominal pain]

BACKGROUND

Epiploic appendagitis (AE) is a rare cause of acute abdomen and is often misdiagnosed as other common causes of acute abdomen, such as acute appendicitis, cholecystitis or diverticulitis due to its low incidence and its nonspecific clinical picture. This study presents the clinical course of AE and typical radiological features for an early and correct diagnosis in order to emphasize the importance of an early and correct diagnosis of AE.

METHODS

This is a retrospective review of 43 patients diagnosed with AE between June 2010 and September 2022 at the Charité - University Hospital Berlin, Campus Benjamin Franklin. The medical records were reviewed regarding clinical und radiological features, anatomical location of the AE und treatment methods.

RESULTS

A total of 43 patients (29 male, 11 female) were diagnosed with AE and almost all patients presented with abdominal pain, except in 8 cases (18.6%). Specific findings in computer tomography (CT) with a typical picture of AE were found in 33 patients (76.7%). AE was mostly localized in the left colon: 12 were found in the sigmoid colon (27.9%), 16 in the descending colon (37.2%) and 5 at the junction of the descending colon and the sigmoid colon (11.6%). Of the patients 28 (65.1%) were admitted for conservative treatment and the rest of the patients were treated as outpatients. No patient underwent surgery, all were treated with analgesics (NSAID) and 17 patients received antibiotics in addition.

CONCLUSION

AE is a self-limiting disease and a common mimic of other serious causes of abdominal pain. Due to the emergence of the widespread use of imaging modalities, an early diagnosis of AE and a conservative approach as first choice of treatment in patients with AE could be established.

A rare case of epiploic appendages infarction within an incisional hernia: a usual complain of unusual cause

Epiploic appendagitis (EA) is an uncommon condition caused by infarction of epiploic appendages “small fat outpouchings present on the outside of the colon wall” because of torsion or thrombosis of the main draining vein. It is sometimes misdiagnosed as diverticulitis or appendicitis. Lab tests usually are normal, and the diagnosis is mainly by computerized tomography (CT) scan. Treatment is conservative as it is a self-limited condition, and the symptoms will resolve spontaneously within 2 weeks. However, surgical appendage removal could be necessary if symptoms increase or continue. Here, we report our experience with a 21-year-old male patient, who presented with a 1-day duration of localized right lower quadrant (RLQ) abdominal pain within 18*10 cm incisional hernia, imaging revealed signs of epiploic appendages infarction within the huge incisional hernia. This case describes an atypical scenario for EA, which was successfully managed with surgery. The final pathology report confirms the diagnosis.

A rare case of epiploic appendages infarction within an incisional hernia: a usual complain of unusual cause

Epiploic appendagitis (EA) is an uncommon condition caused by infarction of epiploic appendages "small fat outpouchings present on the outside of the colon wall" because of torsion or thrombosis of the main draining vein. It is sometimes misdiagnosed as diverticulitis or appendicitis. Lab tests usually are normal, and the diagnosis is mainly by computerized tomography (CT) scan. Treatment is conservative as it is a self-limited condition, and the symptoms will resolve spontaneously within 2 weeks. However, surgical appendage removal could be necessary if symptoms increase or continue. Here, we report our experience with a 21-year-old male patient, who presented with a 1-day duration of localized right lower quadrant (RLQ) abdominal pain within 18*10 cm incisional hernia, imaging revealed signs of epiploic appendages infarction within the huge incisional hernia. This case describes an atypical scenario for EA, which was successfully managed with surgery. The final pathology report confirms the diagnosis.

Bacteremia Secondary to Epiploic Appendagitis (EA)

Epiploic appendages are fat-filled sacs that are generally located along the surface of the large intestine. In most cases, epiploic appendagitis (EA) is described as an ischemic infarction of an epiploic appendage as the result of torsion or spontaneous thrombosis of the central draining vein of the epiploic appendage. The patient described in this report presented with a sudden onset of diffuse abdominal pain, nausea, and fever. CT scan of the abdomen and pelvis with oral contrast revealed EA of the sigmoid colon. Along the course of the admission, the patient became septic with blood cultures growing E. coli. In this case, we present a rare presentation of E. coli sepsis in the setting of EA, a usually uncomplicated and self-resolving presentation of abdominal pain.

Case report: Caecal epiploic appendagitis mimicking acute appendicitis

INTRODUCTION

Acute appendicitis is a very common cause of abdominal pain which is optimally treated surgically. On the other hand, epiploic appendagitis is a self-resolving condition typically managed with analgesia alone, which can also present with severe abdominal pain. Both can present similarly and be difficult to distinguish.

CASE

A 38 year old male presented with 2 days of periumbilical and right iliac fossa pain, with features of localised peritonism on physical exam. Inflammatory markers were only very mildly elevated but a computed tomography scan demonstrated findings in keeping with mild acute appendicitis.

OUTCOME

Laparoscopic appendectomy demonstrated a torted epiploic appendage immediately adjacent to the vermiform appendix. The appendix had very mild inflammatory changes at the base adjacent to the appendage, but otherwise normal macroscopic appearance. Histopathology confirmed periappendicitis without features of acute appendicitis.

CONCLUSION

Right sided epiploic appendagitis can mimic acute appendicitis, and in select patients with right iliac fossa pain there may be a role for serial observation to avoid an unnecessary operation.

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.

Imaging of Mischievous Intra-abdominal Fat Presenting with Abdominal Pain: A Pictorial Review

Aim

To briefly discuss the imaging features of different types of intra-abdominal fat necrosis.

Background

Trauma and ischemic insult may result in intra-abdominal fat necrosis. Fat necrosis may present with acute abdomen, clinically simulating with other etiologies, such as acute diverticulitis and acute appendicitis.

Main body

Imaging plays a crucial role in making the exact diagnosis and differentiating it from other pathologies that may require surgical intervention. Computed tomography (CT) is the most commonly used imaging modality. A small fat attenuation lesion with a hyperattenuating rim in contact with the ventral surface of the sigmoid colon indicates epiploic appendagitis while a larger fat-attenuation lesion on the right side of the abdomen in between the colon and anterior abdominal wall indicates omental infarction. Fat stranding at the root of the mesentery with fat ring sign represents inflammatory mesenteric panniculitis while retractile or sclerosing mesenteritis appears as a fibrotic spiculated mass with or without calcification, mimicking mesenteric carcinoid. In patients with acute pancreatitis, the amount of inflamed fat correlates with clinical severity and outcome.

Conclusions

Familiarity with the imaging features of different types of intraabdominal fat necrosis helps in establishing an accurate diagnosis, thus avoiding unnecessary intervention.

How to cite this article

Patel RK, Mittal S, Singh S. Imaging of Mischievous Intra-abdominal Fat Presenting with Abdominal Pain: A Pictorial Review. Euroasian J Hepato-Gastroenterol 2022;12(1):45–49.

Omental infarction in mild Covid-19 infection

COVID-19 is an infection which can present with various clinical manifestations. While it affects respiratory tract primarily, several other manifestations including gastrointestinal involvements have been reported. The prevalence of all gastrointestinal complaints is approximately 17 percent and diarrhea, nausea/vomiting and abdominal pain are the most common symptoms. In COVID-19, acute abdominal pain requiring surgical evaluation and abdominal imaging is uncommon and there is also a lack of knowledge about COVID-19 related gastrointestinal complications. Here, we report a case of mild COVID-19 infection complicated by omental infarction during the course of the illness.

Right lower quadrant pain: not always appendicitis but epiploic appendagitis of appendix

Epiploic appendagitis is a condition that mimics acute abdomen, causing inflammation of epiploic appendages. This paper aimed to present a case of "epiploic appendagitis of the appendix", which is a rare cause of right lower quadrant pain. A 45-year-old male patient with abdominal pain was referred to the radiology clinic for abdominal CT. The pain localized to the right lower quadrant and no signs of peritoneal irritation were present on physical examination. On images of abdominal CT the diameter of the appendix measured as 7 mm. The wall thickness was within normal limits and no mucosal enhancement noted. Appendiceal air was present in the lumen. An oval lesion of fat density with a hyperdense rim was seen adjacent to the anterior part of the appendix. It was causing striations and heterogeneous appearance in the surrounding mesenteric fat tissue with central areas of high attenuation. The findings noted down as “hyper-attenuating ring sign” and “central dot sign”. These pathognomonic CT findings were consistent with epiploic appendagitis and the case reported as epiploic appendagitis of the appendix. After conservative non-surgical medical treatment symptoms of patient revealed. To prevent unnecessary surgery, it is important to exclude conditions requiring emergency surgical intervention with imaging. The most effective technique recommended for imaging is CT with IV opaque. Increasing awareness and knowledge of radiologists regarding epiploic appendagitis of the appendix will rule out the possibility of potential misdiagnosis in imaging and will avoid the resultant unnecessary surgery.

Epiploic appendagitis - a rare cause of acute lower abdominal pain

Epiploic appendagitis is a rare cause of acute to subacute lower quadrant abdominal pain. It has 2 subtypes: primary and secondary Epiploic appendagitis. Primary epiploic appendagitis is characterized by inflammation of the epiploic appendages caused by torsion or thrombosis of the draining vein of the appendage whereas secondary Epiploic appendagitis may occur in association with other inflammatory etiologies in the abdomen and pelvis. Due to its similarity to other causes of acute abdomen, patients with primary epiploic appendagitis often undergo unnecessary treatment with antibiotics and surgical intervention. We present a case of a middle-aged male who was diagnosed with primary epiploic appendagitis based on imaging studies and was successfully managed with conservative treatment.

Acute Epiploic Appendagitis: An Overlooked Cause of Acute Abdominal Pain

Acute epiploic appendagitis is a benign condition caused by inflammation of the epiploic appendages that are serosal lined outpouchings of the colon lying adjacent to the tenia coli. This rare condition has non-specific clinical findings and is frequently misdiagnosed as either acute diverticulitis or acute appendicitis. However, unlike other surgical causes of acute abdomen, epiploic appendagitis is a self-limited condition and resolves with conservative management. CT of the abdomen plays a vital role in diagnosing this condition and excluding other causes of acute abdomen. This case report highlights the importance of being aware of this rare condition and its consideration in the differential diagnosis of acute lower abdominal pain to avoid unnecessary hospitalization and surgery.

Epiploic Appendagitis Masquerading as Acute Appendicitis: A Report of Two Cases

Epiploic appendagitis (EA) is a rare clinical entity caused by an inflammatory/ischemic process involving the serosal outpouchings of the colon. Its clinical presentation of acute, localised, lower abdominal pain often mimics more common conditions like diverticulitis or appendicitis. The diagnosis of EA is challenging due to the lack of pathognomic clinical features. The definitive diagnosis primarily relies on cross-sectional imaging modalities like abdominal ultrasound or computed tomography (CT). Being a benign and self-limiting condition, it can be managed conservatively with analgesic and anti-inflammatory drugs. We present two cases to highlight EA as an important differential diagnosis for cases of acute lower abdominal pain, crucial to prevent unnecessary antibiotic therapy and surgical interventions.

Acute abdomen in adult revealing unusual complicated epiploic appendagitis: A case report

•

Think about the epiploic appendagitis more frequently when dealing with an obese patient with predispositions.

•

Understand the importance of imagery that avoids unnecessary surgery in case of uncomplicated epiploic appendagitis and make it possible to do a radiological drainage.

•

Always make the necessary differential diagnoses before evoking appendagitis.

Introduction

Epiploic appendagitis is a torsion of fatty appendages of ligamentum trees (1), it’s a rare cause of abdominal pain that usually manifests by right or left iliac fossa pain, reminding of appendicitis, diverticulitis or ischemia of the omentum.

Case presentation

We report the case of a 56 years old male patient admitted for an epigastric pain and a right-upper quadrant abdominal pain, for whom he underwent an abdominal ultrasound and a CT-scan who shown an abscessed mass under colic transverse to the unusual seat.

Discussion

CT scan is still the key modality for diagnosis, avoiding unnecessary surgery. Complications of primary epiploic appendagitis have rarely been described in the literature (Hwang et al., 2013; Hasbahceci et al., 2012). Another more rare complication is appendagitis with associated abscess, in this condition, we must also think about complicated diverticulitis.

The treatment of uncomplicated forms is generally conservative, however, some authors have suggested a surgical method (Saad et al., 2014).

For therapeutic management of its complication, there has been much interest in the use of minimally invasive techniques such as percutaneous drainage to minimize the morbidity and mortality that is associated with surgery (Evidence National Guideline Centre (UK), 2019).

Conclusion

The diagnosis of epiploic appendagitis is still uncommon, CT scan can eliminate other diagnosis of acute abdominal pain such as diverticulitis and appendicitis. It also allows the diagnosis of the rare complicated forms such as abscesses associated with epiploic appendagitis.

The treatment of typical forms is usually conservative, while the complicated form requires surgery because of the potential associated pathology.

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.

A pediatric case report of Epiploic appendagitis presented with abdominal pain

INTRODUCTION

Epilopic appendagitis (EA) is an uncommon condition of abdominal pain caused by the local inflammation of the fat-filled peritoneal outpouchings due to torsion or thrombosis of its vessels leads to ischemia and gangrenous necrosis of the aappendages, as it can cause peritoneal irritation, acute ischemia, and fat necrosis.

CASE REPORT

We present a case of epilopic appendagitis mimicking appendicitis of a 10 years old male, presented to the emergency department with severe right quadrant pain pointedly at the right lumbar area. Associated with constipation and nausea for once. Computed tomography (CT) scan with contrast was performed showing an ovoid fat structure with thin enhancing rim and surrounding inflammatory stranding as well as prominent lymph nodes at hepatic flexure, free fluid and no evidence of appendicitis. The patient was discharged with pain control medications.

DISCUSSION

Epiploic Appendages are mobile, pedunculated peritoneal out pouches. Considering its mobility and narrow pedicle appendages are disposed to torsion leading to appendagitis causing local inflammation, peritoneal irritation, acute ischemia, and fat necrosis. The patient's main complaint would be a subacute lower abdominal pain, left-sided in 60-80% of cases.

CONCLUSION

Early recognition of this condition is crucial to avoid an operation when unnecessary leading to prolonged hospital stays. The management is conservative with analgesic.

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.

Epiploic Appendagitis: An Often Misdiagnosed Cause of Acute Abdomen

Epiploic appendages are peritoneal structures that arise from the outer serosal surface of the bowel wall towards the peritoneal pouch. They are filled with adipose tissue and contain a vascular stalk. Epiploic appendagitis is a rare cause of acute lower abdominal pain. It most commonly results from torsion and inflammation of the epiploic appendages, and its clinical features mimic acute diverticulitis or acute appendicitis resulting in being often misdiagnosed as diverticulitis or appendicitis. This frequently leads to unnecessary hospitalization, antibiotic administration, and unwarranted surgeries. Epiploic appendagitis is usually diagnosed with CT imaging, and the classic CT findings include: (i) fat-density ovoid lesion (hyperattenuating ring sign), (ii) mild bowel wall thickening, and (iii) a central high-attenuation focus within the fatty lesion (central dot sign). It is treated conservatively, and symptoms typically resolve in a few days. Therefore, epiploic appendagitis should be considered as one of the differential diagnosis for acute lower abdominal pain and prompt diagnosis of epiploic appendagitis can avoid unnecessary hospitalization and surgical intervention. In this case report, we discuss a 72-year-old woman who presented with a 2-day history of acute left lower abdominal pain.

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.

Caecal Epiploic Appendagitis Masquerading Clinically as an Acute Appendicitis: A Case Report and Brief Literature Review

A 46-year-old female presented to our emergency department (ED) with a 2-day history of right lower abdominal pain which was associated with nausea and anorexia. Abdominal examination revealed tenderness in the right iliac fossa (RIF) with rebound tenderness and a localized guarding. Urine dipstick was normal, and the pregnancy test was negative. Her laboratory investigations were significant only for a CRP of 16.6. A presumptive clinical diagnosis of acute appendicitis was suggested based on the given history and relevant physical signs. However, an abdominal computed tomography (CT) scan revealed an epiploic appendagitis of the caecum with a normal-looking appendix. She was managed conservatively and responded well and was discharged after 2 days in good health. Though being a relatively rare case of acute localized right-sided lower abdominal pain, caecal epiploic appendagitis should be considered as one of the differential diagnoses with the final diagnosis reached usually by the radiological findings due to the nonspecific nature of clinical and laboratory features.

A case report of epiploic appendagitis as a mimic of acute cholecystitis

INTRODUCTION

Epiploic appendagitis is a rare cause of acute abdominal pain. It's presentation often mimics other causes of acute abdominal pain. It is important for clinicians to be aware of an epiploic appendagitis since a delay in diagnosis can lead to unnecessary hospital stay, antibiotic usage and surgical intervention [1-4]). We present a case of epiploic appendagitis mimicking acute cholecystitis in a rural community hospital.

CASE REPORT

A 54 Caucasian male self-presents to the emergency department on a Saturday with severe right upper quadrant pain. He was initially diagnosed as acute cholecystitis and managed with antibiotics. Due to limitations with out-of-hours radiology, an ultrasound (US) scan was performed two days after admission. This US showed no evidence of cholecystitis or gallstones. A computed tomography (CT) scan was subsequently performed which revealed a diagnosis of epiploic appendagitis. The patient was discharged with analgesia and anti-inflammatories.

DISCUSSION

Epiploic appendagitis can mimic common pathologies causing acute abdominal pain. Unlike its mimics, epiploic appendagitis is a self-limiting condition and its initial management remains conservative. It is diagnosed with imaging studies such as CT scans. It is important for clinicians to be aware of an epiploic appendagitis as a cause for abdominal pain since a delay in diagnosis can lead to unnecessary hospital stay, antibiotic usage and surgical intervention [1-4].

CONCLUSION

A diagnosis of epiploic appendagitis should remain on the list of differential diagnosis for acute abdominal pain. A prompt diagnosis of epiploic appendagitis avoids unnecessary surgical intervention and antibiotic usage.

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%).

Know the name: acute epiploic appendagitis-CT findings and review of literature

Epiploic appendages are normal pedunculated peritoneal fat containing outpouchings bordering tenia coli on the anti-mesenteric surface of the colon, extending from caecum to the rectosigmoid. Functions are currently unknown, though some postulate them a blood reservoir. The epiploic appendages can become inflamed, with clinical presentations mimicking that of diverticulitis or acute appendicitis. However, unlike acute diverticulitis or appendicitis, epiploic appendagitis are treated conservatively with antibiotics. Currently, the estimated rate of correct preoperative diagnosis of epiploic appendagitis is 2.5%, but due to benign nature of epiploic appendagitis, it is important to appropriately diagnose it preoperatively and thus preventing unnecessary surgical interventions. Clinical features include focal area of pain, often with normal white blood cell count, that often is common in other differential diagnoses. CT scan plays a crucial role in diagnosis and shows an oval fatty density solid lesion along anterior colonic wall surface, surrounded by a rim of fat stranding. Treatment is conservative and involves use of anti-inflammatory medication.

Core curriculum illustration: epiploic appendagitis

This is the 45th installment of a series that will highlight one case per publication issue from the bank of cases available online as part of the American Society of Emergency Radiology (ASER) educational resources. Our goal is to generate more interest in and use of our online materials. To view more cases online, please visit the ASER Core Curriculum and Recommendations for Study online at: http://www.erad.org/page/CCIP_TOC.

Dissimilar Pain of Primary Epiploic Appendagitis and Malabsorption

Primary Epiploic Appendagitis (PEA) is a rare cause of acute or subacute abdominal complaints and non-migratory pain. Usually the diagnosis of PEA is made when Computed Tomography (CT) reveals characteristic figures. Nonspecific abdominal complaints including diffuse abdominal pain may be caused by carbohydrate and/or protein malabsorption. We report a case of a patient with PEA who recovered without medication or surgical treatment within a few days. Eight months later, he was diagnosed with lactose- and histamine malabsorption and Helicobacter pylori infection. The malabsorption was treated successfully with an individually-tailored diet free of culprit triggers and the Helicobacter pylori infection was eradicated. A localized non-migratory abdominal pain caused by PEA needs to be differentiated from nonspecific abdominal complaints due to malabsorption and Helicobacter pylori infection.

Abdominal pain - learning when not to intervene!

Epiploic appendagitis (EA) is an uncommon cause of abdominal pain. It is a benign condition but may mimic other serious causes of acute abdomen such as appendicitis, diverticulitis, and gynecological emergency in severe cases. Knowledge of this condition in the differential diagnosis of abdominal pain can save unnecessary hospital admission, antibiotics, and surgery. In this article, we present the case of a 43-year-old female who presented to our hospital with a 2-day history of right lower quadrant abdominal pain and diarrhea. She was diagnosed with EA with computed tomography of abdomen with contrast and was managed conservatively with good outcome.

Co-occurrence of carbohydrate malabsorption and primary epiploic appendagitis

Unspecific abdominal complaints including bloating and irregular bowel movements may be caused by carbohydrate malabsorption syndromes, e.g., lactose and fructose malabsorption. These symptoms were investigated with hydrogen (H₂) breath tests and correlated to carbohydrate malabsorption. During performing these H₂-breath tests the patient presented with an acute, localized, non-migratory pain in the left lower abdominal quadrant. Primary epiploic appendagitis is a rare cause of abdominal acute or subacute complaints and diagnosis of primary epiploic appendagitis (PEA) is made when computed tomography reveals a characteristic lesion. We report on a patient with co-occurrence of lactose and fructose malabsorption, which was treated successfully with a diet free of culprit carbohydrates, with PEA recovering without medication or surgical treatment within few days. Since the abdominal unspecific symptoms had been present for months, they appeared not to be correlated to the acute localized abdominal pain, therefore we speculate on a random co-occurrence of combined carbohydrate malabsorption and PEA.

A case of epiploic appendagitis with acute gastroenteritis

Epiploic appendagitis is an inflammation of the epiploic appendage in which the small sacs projecting from the serosal layer of the colon are positioned longitudinally from the caecum to the rectosigmoid area. Epiploic appendagitis is rare and self-limiting; however, it can cause sudden abdominal pain in children. Epiploic appendagitis does not typically accompany other gastrointestinal diseases. Here, we report on a healthy eight-year-old girl who presented with abdominal pain, fever, vomiting, and diarrhea. Based on these symptoms, she was diagnosed with acute gastroenteritis, but epiploic appendagitis in the ascending colon was revealed in contrast computed tomography (CT). The patient was treated successfully with conservative management. CT is beneficial in diagnosis and further assessment of epiploic appendagitis. Pediatricians need to be aware of this self-limiting disease and consider it as a possible alternate diagnosis in cases of acute abdominal pain.

Recurrent epiploic appendagitis and peritoneal dialysis: A case report and literature review

Epiploic appendagitis (EA) is rare cause of acute or subacute abdominal pain in patients on peritoneal dialysis (PD), where the diagnosis can be challenging as the clinical features, laboratory markers and imaging characteristics have not been described previously in this group of patients. Here, we present the management of a case of EA in a patient on PD and review published literature pertinent to the subject. The importance of establishing the diagnosis early by laparoscopy is emphasised.

Primary epiploic appendagitis and fructose malabsorption

Primary epiploic appendagitis (PEA) is a rare cause of abdominal acute or subacute complaints. Diagnosis of PEA is made when computed tomography (CT) reveals a characteristic lesion. We report on contrast-enhanced CT images of a patient with PEA and regression of inflammation and the reduction in size of the inflamed appendage over the time period of 4 months. Patients with PEA usually recover without medication or surgical treatment within a few weeks. However, due to continuing bloating and irregular bowel movements we investigated carbohydrate malabsorption and diagnosed a fructose malabsorption. Bloating and irregular bowel movements in this patient with PEA were correlated to carbohydrate malabsorption and were treated successfully with a diet free of culprit carbohydrates.