Table of Contents    
CASE REPORT
Year : 2018  |  Volume : 9  |  Issue : 2  |  Page : 282-284  

Epiploic appendagitis: A self-limiting cause of abdominal pain


1 Department of Internal Medicine, Yale New Haven Health, Bridgeport Hospital, Bridgeport, CT 06610, USA
2 Department of Internal Medicine, Bridgeport Hospital, Bridgeport, CT 06610, USA
3 Department of Radiology, Bridgeport Hospital, Bridgeport, CT 06610, USA

Date of Web Publication20-Jun-2018

Correspondence Address:
Prabin Sharma
Department of Internal Medicine, Bridgeport Hospital, Bridgeport, CT 06610
USA
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jnsbm.JNSBM_173_17

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   Abstract 

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

Keywords: Abdominal pain, epiploic appendagitis, mesenteric panniculitis, sclerosing mesenteritis


How to cite this article:
Sharma P, Chkhikvadze T, Sharma P. Epiploic appendagitis: A self-limiting cause of abdominal pain. J Nat Sc Biol Med 2018;9:282-4

How to cite this URL:
Sharma P, Chkhikvadze T, Sharma P. Epiploic appendagitis: A self-limiting cause of abdominal pain. J Nat Sc Biol Med [serial online] 2018 [cited 2018 Jul 20];9:282-4. Available from: http://www.jnsbm.org/text.asp?2018/9/2/282/234703


   Introduction Top


Appendices epiploicae are pouches of peritoneum arising from the serosal surface of the colon, extending from the cecum to the rectosigmoid junction and are connected to the colon by a vascular stalk.[1],[2] First described by Vesalius in 1543,[3] a human adult colon has 50–100 of these appendages. Virchow in 1863 used various terminologies to describe these appendages; “peritoneal loose body” or “peritoneal mice” when they become infarcted and calcified and “parasitized appendix epiploica” when they reattach themselves to the splenic surface.[3],[4],[5],[6],[7],[8] Epiploic appendagitis (EA) is a rare condition that refers to the inflammation of the epiploic appendages. There are two types of EA: primary and secondary. Primary EA results from vascular occlusion and inflammation caused by the torsion or thrombosis of the central vein of the epiploic appendage. Secondary EA is also characterized by inflammation of the appendage but usually in association with other abdominopelvic inflammatory processes, e.g., pancreatitis, cholecystitis, diverticulitis, and appendicitis.[2],[9]

EA is a rare diagnosis with <200 cases published in literature. Due to its rarity, there is limited information on its epidemiology, natural history, clinical presentation, treatment, and disease course. We present another case of a primary EA in a middle-aged obese woman who presented to us with lower abdominal pain. She was subsequently diagnosed with primary EA based on imaging and was managed conservatively without surgical intervention. We aim to raise awareness among physicians of this diagnosis and we share our experience of a successful medical management.


   Case Report Top


A 51-year-old hispanic female presented to the emergency department with bilateral lower quadrant abdominal pain for 5 days. The pain was described as stabbing type, of 5/10 in severity with no radiation and was accompanied with nausea, nonbilious vomiting, and diarrhea. She had no history of similar pain in the past and she did not provide history of sick contacts or unusual food intake. She had no fever, chills, night sweats, hematemesis, melena, or hematochezia. Her past medical problems included depression, asthma, and nephrolithiasis. Surgical history included a cesarean section about 30 years before this presentation.

Vital signs were normal with blood pressure of 107/65 mmHg, temperature of 36.6°C and respiratory rate of 16/min. Her body mass index was 33.6 kg/m 2. Physical examination was significant for left lower quadrant tenderness. Laboratory workup including complete blood count, basic metabolic panel, liver function test, and lipase was normal. Stool studies including stool pathogens and clostridium difficile assay were normal. A computed tomography (CT) scan of the abdomen and pelvis was obtained which was read as 3.5 cm area of focal inflammation in the fat in a region bounded by sigmoid colon, right anterior aspect of the urinary bladder, and right fallopian tube suggestive of mesenteric panniculitis. The patient was thus started on treatment with prednisone and tamoxifen with a provisional diagnosis of mesenteric panniculitis. Testing for chlamydia, gonorrhea, and genital gram stain was all negative. Further blood work revealed erythrocyte sedimentation rate (ESR) of 50 mm/h (reference range: 0–21 mm/h) and C-reactive protein (CRP) level of 11.6 mg/dL (reference range: 0.0–0.8 mg/dL). Antinuclear antibody was positive with a titer of 1:80 (reference range: <1:80 negative) and it had a speckled pattern. C3 and C4 complement levels were both normal at 175 mg/dL (reference range: 70–180 mg/dL) and 29 mg/dL (reference range: 14–40 mg/dL), respectively. Antineutrophil cytoplasmic antibody was negative, double-stranded DNA antibody was <10.0 IU/ml (reference range: <10.0 IU/ml), and IgG4 level was normal. The patient was also evaluated by the surgical and gynecological team who recommended conservative management. Symptoms persisted despite treatment and thus a repeat CT abdomen and pelvis was obtained 4 days later which showed fat density ovoid structure adjacent to the sigmoid colon, demonstrating a high-density ring with mild surrounding inflammatory fat stranding and thickening of the adjacent peritoneal lining suggestive of EA [Figure 1] and [Figure 2]. Treatment was then switched to ketorolac and metoclopramide. She had a gradual resolution of symptoms; surgical intervention was avoided and she was discharged home.
Figure 1: Computed tomography scan of the abdomen and pelvis (axial view) showing a 3.5 cm fat density ovoid structure adjacent to the sigmoid colon, demonstrating a high-density ring with mild surrounding inflammatory fat stranding and thickening of the adjacent peritoneum

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Figure 2: Computed tomography scan of the abdomen and pelvis (Coronal view) showing a 3.5 cm fat density ovoid structure adjacent to the sigmoid colon, demonstrating a high-density ring with mild surrounding inflammatory fat stranding and thickening of the adjacent peritoneum

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   Discussion Top


EA is a rare cause of localized, acute abdominal pain. Dockerty et al. in 1956 were the first to use the terminology “Epiploic appendagitis.”[8] EA mimics various other intra-abdominal pathologies which include mesenteric panniculitis, omental infarction, appendicitis, diverticulitis, and fat-containing tumor among others.[2],[9] Exact incidence and prevalence of EA is not reported. Some literature report a male preponderance, primarily affecting patients between the 4th and 5th decade of life.[2] It is seen with increased frequency in obese patients, patients with hernia, and those undergoing heavy exercise.[2],[10]

The most common clinical presentation includes sudden onset of lower quadrant abdominal pain, most often on the left side. Other symptoms that may accompany include fever, nausea, vomiting, bloating or fullness, distension, and diarrhea.[6],[11] Laboratory workup is usually normal, but in some cases, neutrophilic leukocytosis, elevation of ESR, and elevation of CRP has been reported.[12],[13]

Before the development of advanced diagnostic imaging techniques, EA was a surgical diagnosis. Danielson et al. described characteristic findings of EA by CT scan in 1986 for the first time.[14] EA is now primarily diagnosed based on these CT scan findings. The presence of intraperitoneal fluid or inflammation around the appendages is usually necessary to distinguish EA on CT imaging. Hallmark findings are oval shaped, fat density paracolic lesion about 2–4 cm in size, surrounded by inflammatory changes which include thickened peritoneal lining and fat stranding as seen in our patient. Furthermore, with increasing use of CT scan, incidental diagnosis of EA is also being reported. Ultrasound of abdomen and pelvis can also help in the diagnosis, where the typical findings include a noncompressible hyperechoic mass with a surrounding hypoechoic rim at the site of maximum tenderness and no central blood flow on Doppler studies.[2],[14],[15] Most common sites of the bowel affected in descending order of frequency include sigmoid colon, descending colon, and the right hemicolon.[2] Differential diagnosis of EA should include acute cholecystitis, acute diverticulitis, acute appendicitis, abscess, mesenteric panniculitis, mesenteric adenitis, omental metastases, ovarian torsion, urachal cyst, ectopic pregnancy, ileitis, dropped gallstones, and dropped appendicoliths (especially for calcified epiploic appendages).[16],[17]

EA is a benign inflammatory condition with a self-limited course. Management usually does not require hospitalization, antibiotics, or surgical intervention. Patients can be managed medically with oral nonsteroidal anti-inflammatory medications or opioid analgesics depending on the severity and clinical response.[18] Typically, symptoms resolve spontaneously within 2 weeks.[6] The CT findings may take longer to resolve, usually up to 6 months.[2] Surgical management may be indicated in patients whose symptoms fail to resolve with conservative treatment or patients who develop bowel obstruction or intussusception.[19],[20],[21] Unresolved EA may result in complications leading to intestinal obstruction, intussusception, and abscess formation.[21]

In summary, we present a case of a middle-aged woman who presented with acute left lower quadrant abdominal pain. She was evaluated with a CT scan of the abdomen and pelvis which was first read as mesenteric panniculitis. A repeat CT abdomen and pelvis obtained due to persistence of symptoms confirmed the diagnosis of EA due to the characteristic findings. As seen in our case, many other conditions mimic EA. Based on the first CT scan, our patient was mistakenly believed to have mesenteric panniculitis. Mesenteric panniculitis or sclerosing mesenteritis is characterized by fibrotic and inflammatory changes in the bowel mesentery which may be confused with EA.[22] Diagnosis became more evident when she failed to respond to the initial treatment and a repeat scan was obtained. We were able to avoid inadvertent surgical intervention in this particular case.


   Conclusion Top


An inability to appropriately differentiate EA from other acute inflammatory abdominal pathologies such as acute diverticulitis and appendicitis leads to surgical intervention, increased length of hospitalization, as well as increased postoperative morbidity. Clinicians should be aware of EA as a differential of lower quadrant abdominal pain. Our case highlights the role of an astute radiologist in outlining the characteristic radiologic features of EA.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
   References Top

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Hwang JA, Kim SM, Song HJ, Lee YM, Moon KM, Moon CG, et al. Differential diagnosis of left-sided abdominal pain: Primary epiploic appendagitis vs. colonic diverticulitis. World J Gastroenterol 2013;19:6842-8.  Back to cited text no. 13
    
14.
Danielson K, Chernin MM, Amberg JR, Goff S, Durham JR. Epiploic appendicitis: CT characteristics. J Comput Assist Tomogr 1986;10:142-3.  Back to cited text no. 14
    
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Rioux M, Langis P. Primary epiploic appendagitis: Clinical, US, and CT findings in 14 cases. Radiology 1994;191:523-6.  Back to cited text no. 15
    
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Gupta N, Sapire JM, Marrinan G, Bansal I, Kumar Y. Some stones are precious-extraluminal appendicoliths. Indian J Surg 2016;78:507-8.  Back to cited text no. 16
    
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Gelrud A, Cárdenas A, Chopra S. Epiploic appendagitis. Friedman LS & Grover S (Ed) UpToDate. Waltham MA: UpToDate Inc.; 2017 Available from: http://www.uptodate.com. [Last accessed on 2017 Oct 28].  Back to cited text no. 17
    
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Legome EL, Belton AL, Murray RE, Rao PM, Novelline RA. Epiploic appendagitis: The emergency department presentation. J Emerg Med 2002;22:9-13.  Back to cited text no. 18
    
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Sangha S, Soto JA, Becker JM, Farraye FA. Primary epiploic appendagitis: An underappreciated diagnosis. A case series and review of the literature. Dig Dis Sci 2004;49:347-50.  Back to cited text no. 19
    
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21.
Puppala AR, Mustafa SG, Moorman RH, Howard CH. Small bowel obstruction due to disease of epiploic appendage. Am J Gastroenterol 1981;75:382-3.  Back to cited text no. 21
    
22.
Sharma P, Yadav S, Needham CM, Feuerstadt P. Sclerosing mesenteritis: A systematic review of 192 cases. Clin J Gastroenterol 2017;10:103-11.  Back to cited text no. 22
    


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