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Wong J, Lau KK. Prevalence of SIRS with primary epiploic appendagitis. Emerg Radiol 2024; 31:17-23. [PMID: 38049601 DOI: 10.1007/s10140-023-02191-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2023] [Accepted: 11/21/2023] [Indexed: 12/06/2023]
Abstract
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.
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Affiliation(s)
- Julian Wong
- Diagnostic Imaging, Monash Health, Melbourne, VIC, Australia.
| | - Kenneth K Lau
- Diagnostic Imaging, Monash Health, Melbourne, VIC, Australia
- Faculty of Medicine, Monash University, Clayton, VIC, Australia
- Sir Peter MacCallum Department of Oncology, University of Melbourne, VIC, Australia
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Kefala MA, Tepelenis K, Stefanou CK, Stefanou SK, Papathanakos G, Kitsouli A, Tepelenis N, Kitsoulis P. Primary Epiploic Appendagitis Mimicking Acute Appendicitis: A Case Report and Narrative Review of the Literature. THE KOREAN JOURNAL OF GASTROENTEROLOGY 2021; 76:88-93. [PMID: 32839372 DOI: 10.4166/kjg.2020.76.2.88] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/08/2020] [Revised: 06/27/2020] [Accepted: 07/02/2020] [Indexed: 11/03/2022]
Abstract
Primary epiploic appendagitis is uncommon and is estimated to induce 1.1-1.3% of all abdominal pain. We report a 42-year-old male who appeared in the morning in the emergency department with abdominal pain localized in the right lower abdomen and associated with anorexia and nausea. Clinical examination, laboratory tests, and abdominal ultrasound revealed deep tenderness at Mc Burney point and a mild elevation of CRP (0.7 mg/dL). In the evening, the symptoms were exacerbated, and a diagnostic laparoscopy was performed. Intra-operatively, the appendix was normal and a twisted, necrotic epiploic appendage originating from the antimesenteric border of the mid ascending colon was found. Laparoscopic resection of the necrotic epiploic appendage and prophylactic appendectomy was carried out. Histology indicated the diagnosis of the necrotic epiploic appendage. Postoperatively, the patient recovered without complications. Although the preoperative diagnosis of primary epiploic appendagitis has improved due to abdominal ultrasound and mainly CT, there are still cases which are diagnosed during laparoscopy. The treatment of choice is conservative management, while the use of antibiotics remains controversial. The relapse and complication rates are rare. Surgical excision, particularly laparoscopic, should be considered in cases of uncertain diagnosis, persistent symptoms, or recurrence.
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Affiliation(s)
- Maria Alexandra Kefala
- Department of Pediatrics, General Hospital of Ioannina "G. Xatzikosta", Ioannina, Greece
| | - Kostas Tepelenis
- Department of Surgery, University Hospital of Ioannina, Ioannina, Greece
| | | | | | | | | | | | - Panagiotis Kitsoulis
- Anatomy-Histology-Embryology, University of Ioannina, Ioannina, Greece.,Department of Orthopaedics, University Hospital of Ioannina, Ioannina, Greece
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Mert A, Mırcık E. Primary Epiploic Appendagitis: A Case Report. Cureus 2021; 13:e14060. [PMID: 33898143 PMCID: PMC8059666 DOI: 10.7759/cureus.14060] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
Primary epiploic appendagitis (PEA) is a rather uncommon and self-limiting cause of acute abdomen managed conservatively. Overlapping clinical features with other common causes of acute abdomen usually requiring surgical intervention, and rare occurrences have led to misdiagnosis of the condition and unnecessary surgical intervention. However, with identification of definite characteristic features on imaging (computed tomography [CT] scan) has led to easier diagnosis and avoidance of exploratory laparotomy. Here we present a case of PEA in a 34-year-old otherwise healthy Caucasian male with a chief complaint of acute left-sided abdominal, flank and inguinal pain with diarrhea. Laboratory investigation reports were more or less within normal limits; CT scan confirmed the diagnosis of PEA. The patient was managed successfully with an oral antibiotic and a non-steroidal anti-inflammatory drug. CT scan should be done in cases of acute abdomen (if not absolutely contraindicated) for confirmation of diagnosis, as in our case CT scan helped in confirmation of diagnosis of PEA and thus avoided unnecessary surgical intervention. However, with the current advances in radiological tools, correct diagnosis of acute abdomen has become a lot easier, leading to timely surgical intervention and also at the same time avoidance of unnecessary exploratory laparotomy. Again, with documentation of specific characteristic radiological features of PEA, diagnosis of PEA has become much easier. After careful correlation among clinical, radiological, and laboratory findings, diagnosis of PEA was confirmed. The patient was managed conservatively at home with the advice of plenty of fluid intake and bed rest. Furthermore, he was prescribed an oral antibiotic (ciprofloxacin) and a non-steroidal anti-inflammatory drug (ibuprofen) empirically for seven days to prevent further complications like adhesions, bowel obstruction, intussusception, peritonitis, and local abscess formation. The patient recovered completely (the symptoms and signs resolved clinically) after one week. To conclude, it can be said, although rare in occurrence and lacking in specific presenting features, diagnosis of PEA has become easier with imaging techniques like CT scan and magnetic resonance imaging (MRI); thus, with prior awareness regarding this disease among physicians, unnecessary surgical interventions can be avoided.
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Affiliation(s)
- Alpaslan Mert
- School of Health Sciences, Beykent University, Istanbul, TUR
| | - Emre Mırcık
- Health Management, Private Hurrem Sultan Hospital, Istanbul, TUR
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Zadeh ES, Kindermann J, Dietrich CF, Görg C, Bleyl T, Alhyari A, Trenker C. Clinical Awareness and Acceptance of Sonographically Diagnosed Epiploic Appendagitis (EA): A Retrospective Analysis of EA in a Single Tertiary Academic Referral Center. Ultrasound Int Open 2021; 6:E87-E93. [PMID: 33728395 PMCID: PMC7954640 DOI: 10.1055/a-1371-9359] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2020] [Accepted: 01/24/2021] [Indexed: 12/18/2022] Open
Abstract
Purpose
To describe the clinical awareness and acceptance of ultrasound-diagnosed acute epiploic appendagitis (EA) and their importance to avoid unnecessary therapeutic and imaging measures.
Patients and Methods
The data were obtained of n=54 patients with acute, localized, peritonitic pain and EA diagnosed by B-mode ultrasound and contrast-enhanced ultrasound examination from November 2003 to September 2020. All examinations were performed by a German Society for Ultrasound in Medicine (DEGUM) Level III qualified examiner. Based on documentation by the treating physicians, the clinical awareness and acceptance of EA diagnosis was determined in all patients and compared between subgroups diagnosed before 2013 and from 2013 onwards. In 2013, a local educational training program regarding the diagnosis of and therapy for EA was initiated for physicians.
Results
In all patients, EA was sonographically diagnosed by a DEGUM level III qualified examiner. At enrollment, EA was mentioned as a suspected clinical diagnosis in n=1/54 (1.9%) patient. Furthermore, in n=39/54 (72.2%) cases, the EA was documented and accepted by the treating physicians at the time of patient discharge as the final clinical diagnosis. The clinical acceptance was significantly higher from 2013 onwards compared with before 2013 (p<0.05). Moreover, in n=26/54 (48.1%) patients, unnecessary therapeutic measures were initiated, with no significant difference between pre-2013 and post-2013 numbers (p>0.05).
Conclusion
In our retrospective study, we showed that awareness and acceptance of the disease EA are low. Low diagnostic acceptance of EA by the clinician leads to unnecessary therapeutic and imaging measures and is a general problem related to rare diseases in the healthcare system.
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Affiliation(s)
- Ehsan Safai Zadeh
- Interdisciplinary Center of Ultrasound Diagnostics, University Hospital of Giessen and Marburg, Campus Marburg, Marburg, Germany
| | - Julia Kindermann
- Interdisciplinary Center of Ultrasound Diagnostics, University Hospital of Giessen and Marburg, Campus Marburg, Marburg, Germany
| | - Christoph F Dietrich
- Department of General Internal Medicine, Hirslanden Klinik Beau-Site, Bern, Switzerland
| | - Christian Görg
- Interdisciplinary Center of Ultrasound Diagnostics, University Hospital of Giessen and Marburg, Campus Marburg, Marburg, Germany
| | - Tobias Bleyl
- Gastroenterology, Endocrinology, Metabolism and Clinical Infectiology, University Hospital of Giessen and Marburg, Campus Marburg, Marburg, Germany
| | - Amjad Alhyari
- Gastroenterology, Endocrinology, Metabolism and Clinical Infectiology, University Hospital of Giessen and Marburg, Campus Marburg, Marburg, Germany
| | - Corinna Trenker
- Haematology, Oncology and Immunology, University Hospital of Giessen and Marburg, Campus Marburg, Marburg, Germany
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MDCT in the Setting of Suspected Colonic Diverticulitis: Prevalence and Diagnostic Yield for Diverticulitis and Alternative Diagnoses. AJR Am J Roentgenol 2020; 215:39-49. [DOI: 10.2214/ajr.19.21852] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
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Choi YI, Woo HS, Chung JW, Shim YS, Kwon KA, Kim KO, Kim YJ, Park DK. Primary epiploic appendagitis: compared with diverticulitis and focused on obesity and recurrence. Intest Res 2019; 17:554-560. [PMID: 31602962 PMCID: PMC6821941 DOI: 10.5217/ir.2018.00148] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/21/2018] [Accepted: 05/13/2019] [Indexed: 11/05/2022] Open
Abstract
Background/Aims There is limited data to compare the clinical characteristics and recurrence rates between left-sided primary epiploic appendagitis (PEA) versus left-sided acute colonic diverticulitis (ACD), and right-sided PEA versus right-sided ACD, respectively. Methods We retrospectively reviewed the medical records and radiologic images of the patients who presented with left-sided or right-sided acute abdominal pain and had computer tomography performed at the time of presentation showing radiological signs of PEA or ACD between January 2004 and December 2014. We compared the clinical characteristics of left PEA versus left ACD and right PEA versus right ACD, respectively. Results Fifty-six patients (left:right = 27:29) and 308 patients (left:right = 24:284) were diagnosed with symptomatic PEA and ACD, respectively. Left-sided PEA were statistically significantly younger (50.2 ± 15.4 years vs. 62.1 ± 15.8 years, P= 0.009), more obese (body mass index [BMI]: 26.3 ± 2.9 kg/m2 vs. 22.3 ± 3.1 kg/m2 , P< 0.001), and had more tendencies with normal or mildly elevated high-sensitivity C-reactive protein (hsCRP) (1.2 ± 1.3 mg/dL vs. 8.4 ± 7.9 mg/dL, P< 0.001) than patients with left-sided ACD. The discriminative function of age, BMI and CRP between left-sided PEA versus left-sided ACD was 0.71 (cutoff: age ≤ 59 years, sensitivity of 66.7%, specificity of 77.8%), 0.84 (cutoff: BMI > 24.5 kg/m2 , sensitivity of 80.0%, specificity of 80.0%) and 0.80 (cutoff: CRP < 1.8 mg/dL, sensitivity of 72.2%, specificity of 85.7%). Conclusions If patients with left lower quadrant abdominal pain are less than 60 years, obese (BMI > 24.5 kg/m2 ) with or without normal to mild elevated CRP levels (CRP < 1.8 mg/dL), it might be necessary for clinicians to suspect the diagnosis of PEA rather than ACD.
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Yang L, Jia M, Han P. Primary epiploic appendagitis as an unusual cause of acute abdominal pain in a middle-aged male: A case report. Medicine (Baltimore) 2019; 98:e16846. [PMID: 31415410 PMCID: PMC6831169 DOI: 10.1097/md.0000000000016846] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
RATIONALE Primary epiploic appendagitis (PEA) is a rare cause of acute abdomen caused by spontaneous torsion or venous thrombosis of epiploic appendices, it commonly manifests with acute lower quadrant pain, thus may mimic acute diverticulitis, appendicitis, or mesenteric infarction. PATIENT CONCERNS In this case report, we report a 44 years old man who presented with persistent sharp pain in the left lower quadrant abdomen, Laboratory tests were mostly normal, contrast enhanced computed tomography (CECT) revealed a slightly high density shadow with fat foci in the middle was presented around the local descending colon, accompanied by the adjacent peritoneal thickening. DIAGNOSES He was diagnosed with PEA as confirmed by an abdominal contrast enhanced computed tomography (CECT) scan. INTERVENTIONS He was followed up in the clinic without any dietary restrictions, antibiotic or analgesic drugs use. OUTCOMES The abdominal pain gradually subsided a week later, and there were no recurrence of the symptoms during follow-up. LESSONS In our case, the diagnosis of PEA using CECT allows the patient to avoid surgery and other invasive treatment.
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Affiliation(s)
- Lan Yang
- Department of Ultrasound, the Fifth People's Hospital of Nanchong
| | - Min Jia
- Department of radiology, Nanchong Central Hospital, Nanchong
| | - Ping Han
- Department of Gastroenterology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
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Impact of Radiology Report Wording on Care of Patients With Acute Epiploic Appendagitis. AJR Am J Roentgenol 2019; 212:1265-1270. [PMID: 30860892 DOI: 10.2214/ajr.18.20747] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
OBJECTIVE. The purpose of this study was to evaluate the association between the diagnostic certainty expressed by the wording of CT report impressions and subsequent use of standard treatment with analgesics versus nonstandard antibiotic administration in patients with acute epiploic appendagitis (EA). MATERIALS AND METHODS. Demographic, clinical, and radiologic data from a 10-year cohort of patients with acute EA were retrospectively analyzed and correlated with standard treatment with analgesics versus nonstandard treatment with antibiotics. A level of certainty was assigned to the CT report language based on the wording of the impression statements by two radiologists; their interreader agreement was assessed with kappa statistics. Bivariate analyses were performed to correlate all variables with antibiotic administration and to assess for collinearity. Multivariate logistic regression was performed to identify independent predictors of antibiotic use in patients with acute EA. RESULTS. Of 124 patients with CT-diagnosed acute EA, 22% (27/124) received antibiotic treatment. After the CT report impressions were evaluated, 27% (34/124) were categorized as low certainty and 73% (90/124) as high certainty (κ = 0.958, p < 0.001). Multivariate regression was significant (p < 0.001, Nagelkerke R2 = 0.249) and found CT report impressions' level of certainty (odds ratio [OR] = 6.1, p < 0.001) and evaluation in an outpatient clinic rather than an emergency department (ED) (OR = 4.4, p = 0.003) to be independent predictors of antibiotic administration for patients with acute EA. Outpatient presentation was also correlated with age, abdominal pain duration, and left-colonic involvement in the bivariate analysis (all p ≤ 0.01). CONCLUSION. The diagnostic certainty conveyed by the wording of CT report impressions correlated with antibiotic treatment decisions for patients with acute EA. Patients whose report impressions expressed low rather than high certainty were six times more likely to receive antibiotic therapy; patients evaluated at outpatient clinics rather than EDs were four times more likely.
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Giambelluca D, Cannella R, Caruana G, Salvaggio L, Grassedonio E, Galia M, Midiri M, Salvaggio G. CT imaging findings of epiploic appendagitis: an unusual cause of abdominal pain. Insights Imaging 2019; 10:26. [PMID: 30796645 PMCID: PMC6386757 DOI: 10.1186/s13244-019-0715-9] [Citation(s) in RCA: 26] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2018] [Accepted: 02/04/2019] [Indexed: 12/18/2022] Open
Abstract
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.
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Affiliation(s)
- Dario Giambelluca
- Section of Radiological Sciences, University of Palermo, Via del Vespro 127, 90127, Palermo, Italy
| | - Roberto Cannella
- Section of Radiological Sciences, University of Palermo, Via del Vespro 127, 90127, Palermo, Italy
| | - Giovanni Caruana
- Section of Radiological Sciences, University of Palermo, Via del Vespro 127, 90127, Palermo, Italy
| | - Leonardo Salvaggio
- Section of Radiological Sciences, University of Palermo, Via del Vespro 127, 90127, Palermo, Italy
| | - Emanuele Grassedonio
- Section of Radiological Sciences, University of Palermo, Via del Vespro 127, 90127, Palermo, Italy
| | - Massimo Galia
- Section of Radiological Sciences, University of Palermo, Via del Vespro 127, 90127, Palermo, Italy
| | - Massimo Midiri
- Section of Radiological Sciences, University of Palermo, Via del Vespro 127, 90127, Palermo, Italy
| | - Giuseppe Salvaggio
- Section of Radiological Sciences, University of Palermo, Via del Vespro 127, 90127, Palermo, Italy.
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Epiploic Appendagitis: A Benign Process at Risk of Unnecessary Hospitalization and Interventions. J Gen Intern Med 2017; 32:711. [PMID: 27995428 PMCID: PMC5442003 DOI: 10.1007/s11606-016-3955-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/17/2016] [Revised: 11/04/2016] [Accepted: 12/02/2016] [Indexed: 10/20/2022]
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Iriarte Rodríguez A, Goñi Esarte S, Zozaya Urmeneta JM, Bolado Concejo F, Álvarez Gigli ML. Unusual course of epiploic appendicitis. REVISTA ESPANOLA DE ENFERMEDADES DIGESTIVAS 2015; 107:707-8. [PMID: 26541664 DOI: 10.17235/reed.2015.3796/2015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Epiploic appendicitis is a benign and self-limited disease, due to inflammation of the epiploic appendices. The diagnosis is established by imaging techniques, avoiding treatments, interventions and unnecessary hospitalizations. Management is conservative. Complications are rare and chronicity is exceptional.
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