Acute Epiploic Appendagitis: An Overlooked Cause of Acute Abdominal Pain

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.

Epiploic Appendagitis: A Riddle for Right Lower Quadrant Pain!

Epiploic appendagitis (EA) is inflammation of epiploic appendages, which are pedunculated fatty structures, extend from the cecum to the rectosigmoid junction, and are covered by the peritoneum. Torsion, infarction, and inflammation of it present with acute lower abdominal pain and localized tenderness in a well-looking patient. It poses as diagnostic conundrum due to its rarity and not picked by conventional radiography. A 50-year-old male presented with pain in RLQ for past 1 day, which kept on increasing without any other symptoms. His abdomen was soft with tenderness localized to the right lower quadrant (RLQ), classically at McBurney's point along with mild peritonism. Rest laboratory test, chest, and abdominal X-ray were normal except slight leukocytosis. Ultrasound was inconclusive. A working clinical diagnosis of appendicitis was made. Patient did not consent for surgery and was started on antibiotics with pain killers. With no significant improvement, he underwent CT scan which revealed focal area of soft-tissue attenuation along the lateral wall of ascending colon with fat stranding. He was diagnosed as EA and improved on conservative treatment. EA of RLQ of abdomen mimics acute appendicitis and can be considered as an uncommon differential diagnosis in presence of radiological findings of normal-appearing appendix. CT is the investigation of choice, and treatment is essentially conservative. Further, if appendix is found normal at exploration, surrounding epiploic appendages of the cecum and ascending colon should also be evaluated carefully for inflammation/hematoma/gangrene, besides looking for Meckel's diverticulum.