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Abdominal CT scan , Epiploic Appendagitis (circle)

Epidemiology

Acute Epiploic Appendigitis is usually associated with obesity, hernia and unaccustomed exercise. The inflammation of the epiploic appendages normally resolves on its own for most patients. It is possible however uncommon for acute epiploic appedigitis to result in adhesion, bowel obstruction, intussusception, intraperitoneal loose body, peritonitis, and or Abcess formation . Treatment consists of reassurance of the patient and analgesics. Under non invasive treatment symptoms resolve in two weeks. Hospitalization is not necessary.

Signs and symptoms

The condition commonly occurs in patients in their 40s and 50s predominantly in men.  Epiploic appendagitis is normally misdiagnosed in most patients. Epiploic appendagitis presents with an acute onset of pain, commonly in the left lower quadrant the symptoms often lead to a misdiagnosis for diverticulitis. Diverticulitis manifests with evenly distributed lower abdominal pain accompanied with nausea, fever, and leukocytosis. Patients with acute epiploic appendagitis do not normally report a change in bowel habits, a small amount have constipation or diarrhea.

Mimics of Acute Epiploic Appendagitis

There are several conditions that mimic the symptoms of Epiploic Appendagitis.

Omental infarction: Omental infarction is uncommon reason for acute abdomen. It is similar to acute appendicitis. The pain is of a few days duration centering in the right lower or upper quadrant. Imaging is required to obtain an accurate diagnosis due to the common misdiagnosis of omental infarction as appendicitis or cholecystitis. Omental infarction occurs commonly in pediatric patients approximately 15 percent of cases. The most frequent cause of non- torsion related omental infarction is due to trauma as well as well as thrombosis or the omental veins.  The predisposition for omental infarction includes obesity, strenuous activity, congestive heart failure, digitalis administration, recent abdominal surgery and trauma.” The typical CT findings are a solitary large non-enhancing omental mass with heterogeneous attenuation, which is most often located in the right lower quadrant, deep to the rectus abdominis muscle and either anterior to the transverse colon or anteromedial to the ascending colon” . Omental Infarction can be difficult to differentiate from diverticulitis however omental infarction is not normally attributed with bowel wall thickening. It is rare that the colonic wall will be thickened due to spread of the inflammation from the omentum (a fold of peritoneum connecting or supporting abdominal structures) to the tenia omentalis of the colon.

Diverticulitis : Diverticulitis normally happens in older patients than in epiploic appendagitis. The two inflammatory conditions are quite indistinguishable based on physical manifestations. It’s important to note that patients with diverticulitis will present with nausea, vomiting, fever, elevated leukocyte count rebound tenderness, and will have more extensive lower abdominal pain than patients with epiploic appendacitis. Additionally inflammation from diverticulitis may spread to the epiploic appendages making it difficult to diagnose, for inflammation of the appendices epiploicae may be resultant to other inflammatory conditions in the colonic wall and surrounding mesocolon.

Peritoneal loose body

It is rare however possible for epiploic appendagitis to result in a peritoneal loose body. Peritoneal loose body is a free floating mass of dead fibrous tissue surrounded by several layers of calcification (deposit of calcium salts). The loose body is the result of torsed, infarcted or detached epiploic appendages that eventually become fibrotic (inflammation and scarring) masses. If the loose body becomes large enough it can cause urinary retention (inability to empty bladder) or bowel obstructions.

Background

Epiploic Appendages are also called appendices epiploicae. The appendages themselves are 50-100 appendages that are oriented in two rows anterior and posterior. The appendages are parallel to the superficial section of the taenia coli. Furthermore the appendages are between 0.5 and 5cm long, each appendage is attached with one or two arterioles and a venule within vascular stalks attached to the colon. Torsion of the appendages can happen however it is rare. It’s important to note that torsion (twisting or wrenching motion) of the appendages can cause ischemia which can cause painful symptoms that mimic other conditions such as diverticulitis, and appendicitis. The pain associated with the inflamed appendages is located in the left and sometimes in the right lower abdominal quadrant. Diagnosis of epiploic appendagitis can be challenging due to its infrequency.

Diagnosis

Epiploic appendagitis is more common in patients 40 years in age however it can occur at any age. “The reported ages range from 12 to 82 years. Men are slightly more affected  than woman.” Patients with the epiploic appendagitis describe having a localized, strong, non-migratory sharp pain after eating. Patients generally have tender abdomens as a symptom. Symptoms do not include fever, vomiting, or leukocytic response. The pain usually is located on the right or left lower abdominal quadrant. When there is pain on the lower right lower quadrant it can mimic appendicitis however it is more common to mimic diverticulitis with pain present on the left side.

Radiologic Evaluation

Ultrasound and CT scans are the normal avenue to positive diagnosis of Epiploic Appendagitis.  Ultrasound scans show “an oval, non-compressible hyperechoic mass with a subtle hypoechoic rim directly under the site of maximum tenderness” Normally epiploic appendages cannot be seen on CT scan.  After cross-sectional imaging and the increased use of abdominal CT scan for evaluating lower abdominal pain EA is increasingly diagnosed.  Pathognomonic CT scan data represent EA as 204 cm , oval shaped, fat density lesion, surrounded by inflammation. Contrasting with diverticulitis findings the colonic wall is mostly unchanged.