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A 51-Year-Old Woman With Recurrent Abdominal Pain

 

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What is the diagnosis?

Hint: Recognition of this benign condition can help avoid unnecessary exploratory laparotomies.

       Your Colleagues Responded:
Primary epiploic appendagitis Correct Answer  38%
  Acute omental infarction    10%
  Mesenteric panniculitis    46%
  Appendicitis    4%

    Discussion


    Figure 1B.
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    Figure 2B.
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    An area of increased attenuation within the mesenteric fat in the right upper quadrant surrounding an area of diminished attenuation was noted arising from the transverse colon. The findings were consistent with a radiologic diagnosis of epiploic appendagitis. The epiploic appendages (variably termed appendices epiploicae) are pedunculated adipose projections from the serosal surface of the colon. They appear in the fifth month of fetal life, and each appendage contains a venule and 1-2 arterioles branching off of the vasa recta.[1,2] They form 2 rows that parallel the anterior and posterior taenia coli and run from the cecum to the rectosigmoid junction.[1,3] Each epiploic appendage is approximately 1-2 cm thick and 0.5-5 cm in length,[1,4] with an average length of 3 cm (although appendages up to 15 cm in length have been reported).[5] They are frequently found in association with colonic diverticula and are only visible on diagnostic imaging when surrounded by inflammatory fluid.[4]

    The term primary epiploic appendagitis is reserved for cases resulting from spontaneous torsion, thrombosis, ischemia, or inflammation of an epiploic appendage.[1,2,3] Two central factors contribute to the appendages' propensity for torsion, followed by ischemia and/or infarction: they are freely mobile and have a limited blood supply consisting of 2 narrow end arteries and 1 tortuous vein passing through a narrow pedicle base.[3] The sequence of clinical events is similar to that of appendicitis; namely, an obstruction of some sort, followed by ischemia, thrombosis, and, finally, necrosis. The signs of torsion and necrosis are rarely seen during laparotomy.[6] Secondary epiploic appendagitis is caused by inflammation that extends from adjacent structures (as in diverticulitis, appendicitis, or cholecystitis).[2,3]

    Vesalius was the first to recognize the appendices epiploicae in 1543, but their potential significance was not recognized until 1853, when Virchow proposed that their detachment may be a source of loose intraperitoneal bodies.[5,7,8] These loose appendages may calcify and may be later seen as incidental findings on diagnostic imaging or laparoscopy; when found reattached to intraperitoneal organs, these epiploic appendages are known as "parasitized appendices epiploicae".[8] The exact role of these appendages is not known, although there are a variety of plausible theories as to their function. Epiploic appendages may protect and cushion the colon, like a small omentum; they may act as a blood depository during colonic vessel contraction; they may store fat; and they may even have a role in absorption and the immune response.[1,9,10] They are also used in surgery to protect suture lines and close perforations.[10]

    The sigmoid and the cecum are the most common sites of appendagitis, and of these 2 locations, the sigmoid location is more frequently affected.[11] Because the appendages tend to be larger in the sigmoid, it is not surprising that epiploic appendagitis and its accompanying symptomatology are most often experienced in the left lower quadrant. There is at least 1 case, however, of a patient with a massive sigmoid extending into the right iliac fossa who presented with pain in the right lower quadrant.[1] There is also at least 1 reported case of epiploic appendagitis located within an inguinal hernia sac.[12]

    Primary epiploic appendagitis is most often mistaken for diverticulitis and appendicitis, depending on the location (diverticulitis in cases of left lower quadrant pain and appendicitis in cases of right lower quadrant pain). Interestingly, primary epiploic appendagitis was the final diagnosis made in 2-7% of abdominal CT scans that were performed to rule out diverticulitis, and in 1% of CT scans that looked for appendicitis.[13,14] The pain may also mimic that of a hernia, renal or ureteric colic, omental infarction, acute cholecystitis, and pelvic inflammatory disease (PID).[15]

    Although a review of the literature did not reveal a precise incidence, the rarity of primary epiploic appendagitis is evidenced by the fact that Sand et al were only able to include 10 patients in their study over a period of 3 years, despite conducting their investigation in an urban academic surgical ED.[1] Although it can present at any age, epiploic appendagitis most commonly presents in the fifth decade of life; additionally, it has a slight male preponderance.[1,3,16] There is some controversy as to whether or not this condition is more common in the overweight or obese patient, and there are multiple studies to support either view. A perusal of the many case reports in the literature does, however, seem to support an increased incidence in the overweight or obese patient.[2,12,17] Hanson et al reported that not only is epiploic appendagitis more common in obese patients, but it is also more common in obese patients who have recently lost weight.[18] Strenuous exercise or physical labor by the unaccustomed patient is often recorded as the inciting event.[9,19,20]

    A patient with epiploic appendagitis generally presents with an acute onset of sharp, localized, nonmigratory abdominal pain, most often in the left lower quadrant (as detailed above). The pain may be aggravated by movement, such as deep breathing or coughing.[2] In contrast to other acute abdominal processes, such as appendicitis or diverticulitis, patients are generally without fever, anorexia, nausea, or vomiting. Typically, the laboratory study values, including a complete blood cell (CBC) count, complete metabolic profile, and urinalysis, are within normal limits; however, some patients may present with a mild leukocytosis.[1,2] Sand et al reported an elevated C-reactive protein (CRP) in 2 out of 10 patients in their case series, and the authors hypothesized that the necrosis of epiploic appendagitis triggers an inflammatory response, thereby elevating the CRP.[1]

    Before the advent and common usage of CT scanning, the diagnosis of primary epiploic appendagitis was made by exploratory laparotomy, wherein the inflamed appendage was then ligated and excised.[21] Proper identification of this condition using radiologic studies, specifically by abdominal and pelvic CT scanning, may prevent unnecessary surgical exploration and its associated costs and complications. A study by Rao et al revealed that the average cost per misdiagnosed patient in this situation was $4,117.[22] On CT scans, epiploic appendagitis is represented by a round or oval lesion, typically 2-4 cm in diameter, in close apposition to the colonic wall. Greater than half of these cases are in the sigmoid colon region. Surrounded by periappendageal and pericolic fat stranding, the attenuation of the lesion itself is similar to that of fat, but there is often a thin rim of increased density. A central section of hyperattenuation representing an area of venous thrombosis may be intermittently present.[1,4] The proximal colonic wall is not normally thickened, which helps differentiate this condition from diverticulitis; however, the adjacent visceral peritoneum will occasionally be thickened.[1] It is generally difficult to identify epiploic appendagitis with ultrasonography, but the appendage has been described as an oval, hyperechoic, noncompressible mass with a fine hypoechoic rim at the point of maximal tenderness, adjacent to the colon. On color Doppler ultrasonographic images, a lack of central blood flow is observed; this is an important differentiating factor from appendicitis, which would demonstrate increased blood flow.[1,20,23,24] Magnetic resonance imaging (MRI) is not typically performed in this patient population; however, epiploic appendagitis can be diagnosed by MRI. On MRI, T1- and T2-weighted images demonstrate a focal lesion, with a signal intensity similar to that of fat. The addition of contrast to T1-weighted imaging demonstrates a fatty lesion with rim enhancement.[25] Radiologic changes can persist for weeks,[20] but they generally resolve within 6 months of the acute episode.[4]

    Conservative management with anti-inflammatory medications and pain control are the mainstays of treatment for primary epiploic appendagitis.[1] The patient's symptoms usually regress within 1-2 weeks, although, as noted above, radiologic changes may persist.[1,12] Potential complications that have been reported include adhesions, local abscess formation, intussusception, intraperitoneal loose bodies, bowel obstruction, and peritonitis.[4,11] Sand et al opined that surgical intervention was preferable to expectant management, as 4 of the 10 patients in their study had multiple episodes before their initial presentation, and early surgery would (in theory) prevent complications, such as adhesions and abscess formation.[1] They also noted that the clinician must consider the potential adverse effects that may be associated with the multiple CT scans that would likely be ordered to follow up on these conservatively managed patients.[1]

    In the case presented, the treating surgeon opted for conservative treatment, with over-the-counter nonsteroidal anti-inflammatory medications (NSAIDs) and expectant management. The patient was counseled to follow up in 3 months' time for a possible repeat CT scan and clinical evaluation. It was discussed that if the clinical symptoms or radiologic findings persisted, laparoscopy would be considered at that time.

    CME Test

    Questions answered incorrectly will be highlighted.

    Which of the following conditions is involved in the pathogenesis of primary epiploic appendagitis?
    An intraperitoneal infectious process
    Twisting, stretching, or kinking of the appendages, with impairment of the blood supply
    Detachment of the epiploic appendages
    Fecaliths
    Which of the following choices is most consistently associated with primary epiploic appendagitis?
    Elevated C-reactive protein (CRP)
    Anorexia
    Abdominal pain
    Fever

     
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    References

    1. Sand M, Gelos M, Bechara FG, et al. Epiploic appendagitis clinical characteristics of an uncommon surgical diagnosis. BMC Surgery. 2007;7:11.
    2. Tutar NU, Ozgül E, Og(uz D, Cakir B, Tarhan NC, Cos,kun M. An uncommon cause of acute abdomen-epiploic appendagitis: CT findings. Turk J Gastroenterol. 2007;18:107-110. Abstract
    3. Jain TP, Shah T, Juneja S, Tambi RL. Case of the season: primary epiploic appendagitis: radiological diagnosis can avoid surgery. Semin Roentgenol. 2008;43:4-6. Abstract
    4. Singh A, Gervais DA, Hahn PF, Sagar P, Mueller PR, Novelline RA. Acute epiploic appendagitis and its mimics. Radiographics. 2005;25:1521-34. Abstract
    5. Vinson DR. Epiploic appendagitis: a new diagnosis for the emergency physician. Two case reports and a review. J Emerg Med. 1999;17:827-32. Abstract
    6. Fieber SS, Forman J. Appendices epiploicae: clinical and pathological considerations. AMA Arch Surg. 1953;66:329-38. Abstract
    7. Vesalius A: De humanis corporis fabrica libri septem [Title page: Andreae Vesalii Bruxellensis, scholae medicorum Patauinae professoris De humani corporis fabrica libri septem]. Basileae [Basel, Switzerland]: Ex officina Joannis Oporini: 1543.
    8. Klatt EC. Case 96. The Internet Pathology Laboratory for Medication Education. Mercer University School of Medicine, University of Utah Eccles Health Sciences Library. Available at: http://library.med.utah.edu/WebPath/COW/COW096.html.
    9. Legome EL, Sims C, Rao PM. Epiploic appendagitis: adding to the differential of acute abdominal pain. J Emerg Med. 1999:17:823-826. Abstract
    10. Sirvanci M, Tekelioglu M, Duran C, Yardimci H, Onat L, Ozer K. Primary epiploic appendagitis: CT manifestations. Clin Imaging. 2000:24:357-61. Abstract
    11. Carmichael DH, Organ CH Jr. Epiploic disorders. Conditions of the epiploic appendages. Arch Surg. 1985;120:1167-72. Abstract
    12. Ozkurt H, Karatag O, Karaarslan E, Basak M. Clinical and CT findings of epiploic appendagitis within an inguinal hernia. Diagn Interv Radiol. 2007;13:23-5. Abstract
    13. van Breda Vriesman AC, Puylaert JB. Epiploic Appendagitis and omental infarction: pitfalls and look-alikes. Abdominal Imaging. 2002;27:20-8. Abstract
    14. Zissin R, Hertz M, Osadchy A, Kots E, Shapiro-Feinberg M, Paran H. Acute epiploic appendagitis: CT findings in 33 cases. Emerg Radiol. 2002;9:262-5. Abstract
    15. Quaas AM, Mueller PR, Kickham JM. Epiploic appendagitis mimicking pelvic inflammatory disease (PID). Eur J Obstet Gynecol Reprod Biol. 2007;135:1-2. Abstract
    16. Son HJ, Lee SJ, Lee JH, et al. Clinical diagnosis of primary epiploic appendagitis: differentiation from acute diverticulitis. J Clin Gastroenterol. 2002;34:435-8. Abstract
    17. Lien WC, Lai TI, Lin GS, Wang HP, Chen WJ, Cheng TY. Epiploic appendagitis mimicking acute cholecystitis. Am J Emerg Med. 2004;22:507-8. Abstract
    18. Hanson JM, Kam AW. Paracolic echogenic mass in a man with lower abdominal pain. Is epiploic appendagitis more common than previously thought? Emerg Med J. 2006;23:e17.
    19. Pellosie CJ, Goy R, Jacobsen L. Epiploic appendagitis: a possible work-related etiology. J Occup Environ Med. 2007;49:1053.
    20. Moll� E, Ripollés T, Martínez MJ, Morote V, Roselló-Sastre E. Primary epiploic appendagitis; US and CT findings. Eur Radiol. 1998;8:435-8. Abstract
    21. 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. Abstract
    22. Rao PM, Rhea J, Wittenberg J, Warshaw AL. Misdiagnoses or primary epiploic appendagitis. Am J Surg. 1998;176:81-5. Abstract
    23. Rioux M, Langis P. Primary epiploic appendicitis: clinical, US and CT findings in 14 cases. Radiology. 1994;191:523-6. Abstract
    24. Danse EM, Van Beers BE, Baudrez V, et al. Epiploic appendagitis: color Doppler sonographic findings. Eur Radiol. 2001;11:183-6. Abstract
    25. Sirvanci M, Balci NC, Karaman K, Duran C, Karakas E. Primary epiploic appendagitis: MRI findings. Magn Reson Imaging. 2002;20:137-9. Abstract
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    Authors and Disclosures

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    Author(s)

    Noah Gudel, DO

    Noah Gudel, DO, Resident in Internal Medicine, University of Tennessee Medical Center, Knoxville, TN

    Disclosure: Noah Gudel, DO, has disclosed no relevant financial relationships.

    Lisa M. Rock, MD

    Lisa M. Rock, MD, Clinical Instructor, Case Western Reserve University School of Medicine; Staff Physician, Department of Surgery, University Hospitals of Cleveland, Richmond Medical Center, Cleveland, OH

    Disclosure: Lisa M. Rock, MD, has disclosed no relevant financial relationships.

    Reviewer(s)

    Laurie E. Scudder, MS, NP-C

    Nurse Planner, Medscape; Adjunct Assistant Professor, School of Health Sciences, George Washington University, Washington, DC;  Curriculum Coordinator, Nurse Practitioner Alternatives, Inc., Ellicott City; Nurse Practitioner,  Baltimore City School-Based Health Centers, Baltimore, Maryland

    Disclosure: Laurie E. Scudder, MS, NP-C, has disclosed that she has no relevant financial relationships.

    Editor(s)

    Rick G. Kulkarni, MD, FACEP

    Rick G. Kulkarni, MD, FACEP, Assistant Professor, Yale School of Medicine, Section of Emergency Medicine, Department of Surgery, Attending Physician, Medical Director, Department of Emergency Services, Yale-New Haven Hospital, CT

    Disclosure: Rick Kulkarni, MD, FACEP, has disclosed no relevant financial relationships.

    John Geibel, MD, DSc, MA

    John Geibel, MD, DSc, MA, Vice Chair and Professor, Department of Surgery, Section of Gastrointestinal Medicine and Professor Department of Cellular and Molecular Physiology, Yale University School of Medicine; Director of Surgical Research, Department of Surgery, Yale-New Haven Hospital, New Haven, CT

    Disclosure: John Geibel, MD, DSc, MA, has disclosed relevant financial relationships with AMGEN and AstraZeneca.

    Eugene Lin, MD

    Eugene Lin, MD, Clinical Assistant Professor of Radiology, Department of Radiology, University of Washington Medical Center, Seattle, WA; Attending Physician, Virginia Mason Medical Center, Seattle, WA

    Disclosure: Eugene Lin, MD, has disclosed no relevant financial relationships.

    Luis M. Soler, BA

    Luis M. Soler, BA, Associate Editor, eMedicine/WebMD, New York, NY

    Disclosure: Luis M. Soler, BA, has disclosed no relevant financial relationships.

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