Insights into epiploic appendagitis

Abstract

Epiploic appendagitis is a rare cause of abdominal pain. Diagnosis of epiploic appendagitis, although infrequent, is easily made with CT or ultrasonography in experienced hands. As reported in the literature, most patients with primary epiploic appendagitis are treated conservatively without surgery, with or without anti-inflammatory drugs. A small number of patients are treated with antibiotics and some patients require surgical intervention to ensure therapeutic success. Symptoms of primary epiploic appendagitis usually resolve with or without treatment within a few days. A correct diagnosis of epiploic appendagitis with imaging procedures enables conservative and successful outpatient management of the condition and avoids unnecessary surgical intervention and associated additional health-care costs. Gastroenterologists and all medical personnel should be aware of this rare disease, which mimics many other intra-abdominal acute and subacute conditions, such as diverticulitis, cholecystitis and appendicitis. This article reviews epiploic appendagitis and includes discussion of clinical findings, pathophysiology, diagnosis and therapeutic possibilities.

Key Points

  • Epiploic appendagitis is a rare cause of abdominal pain and may mimic other acute and subacute conditions

  • Diagnosis is made with CT, which reveals a characteristic lesion usually located in one of the lower abdominal quadrants, or ultrasonography, which reveals a hyperechogenic paracolic oval-shaped mass

  • Most patients recover with conservative nonsurgical management with or without the use of anti-inflammatory drugs

  • A correct diagnosis of epiploic appendagitis enables conservative, outpatient management thereby avoiding unnecessary surgical intervention and associated additional health-care costs

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Figure 1: Characteristic abdominal CT findings of epiploic appendagitis in a 40-year-old patient.
Figure 2: A transverse view of an abdominal CT of a 78-year-old patient with epiploic appendagitis.
Figure 3: An ultrasonography image of a 44-year-old patient with epiploic appendagitis.

References

  1. 1

    Sangha, S., Soto, J. A., Becker, J. M. & Farraye, F. A. Primary epiploic appendagitis: an underappreciated diagnosis. A case series and review of the literature. Dig. Dis. Sci. 49, 347–350 (2004).

    Article  PubMed Central  Google Scholar 

  2. 2

    Rioux, M. & Langis, P. Primary epiploic appendagitis: Clinical, US, and CT findings in 14 cases. Radiology 191, 523–526 (1994).

    CAS  Article  PubMed Central  Google Scholar 

  3. 3

    Breda Vriesman, A. C., Lohle, P. N. M., Coerkamp, E. G. & Puylaert, J. B. C. M. Infarction of omentum and epiploic appendage: diagnosis, epidemiology and natural history. Eur. Radiol. 9, 1886–1892 (1999).

    Article  PubMed Central  Google Scholar 

  4. 4

    Almeida, A. T. et al. Epiploic appendagitis: an entity frequently unknown to clinicians—diagnostic imaging, pitfalls, and look-alikes. Am. J. Roentgenol. 193, 1243–1251 (2009).

    Article  Google Scholar 

  5. 5

    Fraser, J. D. et al. Infarction of an epiploic appengage in a pediatric patient. J. Pediatr. Surg. 44, 1659–1661 (2009).

    Article  PubMed Central  Google Scholar 

  6. 6

    Son, H. J. et al. Clinical diagnosis of primary epiploic appendagitis: differentiation from acute diverticulitis. J. Clin. Gastroenterol. 34, 435–438 (2002).

    Article  PubMed Central  Google Scholar 

  7. 7

    Ozdemir, S. et al. Torsion of the primary epiploic appendagitis: a case series and review of literature. Am. J. Surg. (in press).

  8. 8

    Sand, M. et al. Epiploic appendagitis—clinical characteristics of an uncommon surgical diagnosis. BMC Surg. 7, 11 (2007).

    Article  PubMed Central  Google Scholar 

  9. 9

    Hollerweger, A., Macheiner, P., Rettenbacher, T. & Gritzmann, N. Primary epiploic appendagitis: sonographic findings with CT correlation. J. Clin. Ultrasound 30, 481–495 (2002).

    Article  PubMed Central  Google Scholar 

  10. 10

    Ozkurt, H. et al. Brief clinical review: CT findings in epiploic appendagitis. Surgery 141, 530–532 (2007).

    Article  PubMed Central  Google Scholar 

  11. 11

    Sandrasegaran, K., Maglinte, D. D., Rajesh, A. & Akisik, F. M. Primary epiploic appendagitis: CT diagnosis. Emerg. Radiol. 11, 9–14 (2004).

    Article  PubMed Central  Google Scholar 

  12. 12

    Rao, P. M., Rhea, J. T., Wittenberg, J. & Warshaw, A. L. Misdiagnosis of primary epiploic appendagitis. Am. J. Surg. 176, 81–85 (1998).

    CAS  Article  PubMed Central  Google Scholar 

  13. 13

    Rao, P. M., Wittenberg, J. & Lawrason, J. N. Primary epiploic appendagitis: evolutionary changes in CT appearance. Radiology 204, 713–717 (1997).

    CAS  Article  PubMed Central  Google Scholar 

  14. 14

    Singh, A. K. et al. CT appearance of acute epiploic appendagitis. Am. J. Roentgenol. 183, 1303–1307 (2004).

    Article  Google Scholar 

  15. 15

    Macari, M., Laks, S., Hajdu, C. & Babb, J. Caecal epiploic appendagitis: an unlikely occurrence. Clin. Radiol. 63, 895–900 (2008).

    CAS  Article  PubMed Central  Google Scholar 

  16. 16

    Thomas, J. H., Rosatto, F. E. & Patterson, L. T. Epiploic appendagitis. Surg. Gynecol. Obstet. 138, 23–25 (1974).

    CAS  PubMed  PubMed Central  Google Scholar 

  17. 17

    Lester, S. C., French, C. A. & Curtis, G. in Manual of Surgical Pathology (ed. Lester, S. C.) 323–343 (Elsevier, 2006).

    Google Scholar 

  18. 18

    Matsunaga, H., Fuji, Y. & Taniguchi, N. Ultrasonographic findings in epiploic appendagitis. J. Med. Ultrasonics 37, 31–32 (2010).

    Article  Google Scholar 

  19. 19

    Ghahremani, G. G. et al. Appendices epiploicae of the colon: radiologic and pathologic features. Radiographics 12, 59–77 (1992).

    CAS  Article  PubMed Central  Google Scholar 

  20. 20

    Ross, J. A. Vascular loop in the appendices epiploicae: their anatomy and surgical significance, with a review of the surgical pathology of appendices epiploicae. Br. J. Surg. 37, 464–466 (1950).

    CAS  Article  PubMed Central  Google Scholar 

  21. 21

    Vesalius, A. De Humanis Corporis Fabrica Libri Septem (Ex officina Joannis Oporini, Basel, 1543).

    Google Scholar 

  22. 22

    Dockerty, M. B., Lynn, T. E. & Waugh, J. M. A clinicopathologic study of the epiploic appendages. Surg. Gynecol. Obstet. 103, 423–433 (1956).

    CAS  PubMed  PubMed Central  Google Scholar 

  23. 23

    Blinder, E., Ledbetter, S. & Rybicki, F. Primary epiploic appendagitis. Emerg. Radiol. 9, 231–233 (2002).

    PubMed  PubMed Central  Google Scholar 

  24. 24

    Jain, T. P., Shah, T., Juneia, S. & Tambi, R. L. Case of the season: primary epiploic appendagitis: radiological diagnosis can avoid surgery. Semin. Roentgenol. 43, 4–6 (2008).

    Article  PubMed Central  Google Scholar 

  25. 25

    Singh, A. K. et al. Acute epiploic appendagitis and its mimics. Radiographics 25, 1521–1534 (2005).

    Article  PubMed Central  Google Scholar 

  26. 26

    Silva, P. D. & Ripple, J. Laparoscopic diagnosis and treatment of an infarcted epiploic appendage. J. Am. Assoc. Gynecol. Laparosc. 3, 325–327 (1996).

    CAS  Article  PubMed Central  Google Scholar 

  27. 27

    Romaniuk, C. S. & Simpkins, K. C. Case report: pericolic abscess secondary to a torsion of an appendix epiploica. Clin. Radiol. 47, 216–217 (1993).

    CAS  Article  PubMed Central  Google Scholar 

  28. 28

    Görg, C., Egbring, J. & Bert, T. Contrast-enhanced ultrasound of epiploic appendagitis. Ultraschall. in Med. 30, 163–167 (2009).

    Article  Google Scholar 

  29. 29

    Talukdar, R. et al. Epiploic appendagitis: report of two cases. Surg. Today 37, 150–153 (2007).

    Article  PubMed Central  Google Scholar 

  30. 30

    Hiller, N., Berelowitz, D. & Hadas-Halpern, I. Primary epiploic appendagitis: clinical and radiological manifestations. IMAJ 2, 896–898 (2000).

    CAS  PubMed  PubMed Central  Google Scholar 

  31. 31

    Schnedl, W. J., Tillich, M. & Lipp, R. W. Image of the month. Primary epiploic appendagitis. Clin. Gastroenterol. Hepatol. 8, A16 (2010).

    Article  PubMed Central  Google Scholar 

  32. 32

    Lee, P. M. Small bowel obstruction due to epiploic appendagitis. Am. J. Gastroenterol. 85, 771–772 (1990).

    CAS  PubMed  PubMed Central  Google Scholar 

  33. 33

    Kyaw, M. M. & Koehler, P. R. Peudotumor of colon due to adhesion. Radiology 103, 597–599 (1972).

    CAS  Article  PubMed Central  Google Scholar 

  34. 34

    Borg, S. A., Whitehouse, G. H. & Griffith, C. J. A mobile calcified amputated appendix epiploica. Am. J. Roentgenol. 127, 349–350 (1976).

    CAS  Article  Google Scholar 

  35. 35

    Elliot, G. B. & Freigang, B. Aseptic necrosis, calcification, and separation of appendices epiploicae. Am. Surg. 155, 501–505 (1962).

    Google Scholar 

  36. 36

    Jalaguier, A. et al. Accuracy of multidetector computed tomography in differentiating primary epiploic appendagitis from left acute colonic diverticulitis associated with secondary epiploic appendagitis. Emerg. Radiol. 17, 51–56 (2010).

    Article  PubMed Central  Google Scholar 

  37. 37

    Bastidas, J. G. et al. Epiploic appendagitis in a 24-year-old woman. Am. J. Emerg. Med. 26, 838–839 (2008).

    Article  PubMed Central  Google Scholar 

  38. 38

    Osada, H. et al. Multidetector computed tomography diagnosis of primary and secondary epiploic appendagitis. Radiat. Med. 26, 582–586 (2008).

    Article  PubMed Central  Google Scholar 

  39. 39

    Danielson, K., Chernin, M. M., Amberg, J. R., Goff, S. & Durham, J. R. Epiploic appendagitis: CT characteristics. J. Comput. Assist. Tomogr. 10, 142–143 (1986).

    CAS  Article  PubMed Central  Google Scholar 

  40. 40

    Zissin, R. et al. Acute epiploic appendagitis: CT findings in 33 cases. Emerg. Radiol. 9, 262–265 (2009).

    Google Scholar 

  41. 41

    Ammar, H., Looney, S. C. & Malani, A. Epiploic appendagitis. Lancet 373, 2054 (2009).

    Article  PubMed Central  Google Scholar 

  42. 42

    Cianci, R., Filippone, A., Basilico, R. & Storto, M. L. Idiopathic segmental infarction of the greater omentum diagnosed by unenhanced multidetector-row CT and treated successfully by laparoscopy. Emerg. Radiol. 15, 51–56 (2008).

    Article  PubMed Central  Google Scholar 

  43. 43

    Kirchoff, P., Viehl, C. T., Heizmann, O., Oertli, D. & Potthast, S. Image of the month. Arch. Surg. 144, 587 (2009).

    Article  Google Scholar 

  44. 44

    Chou, Y. H. et al. Epiploic appendagitis of the rectosigmoid junction: demonstration with transerectal sonography. J. Clin. Ultrasound 34, 450–453 (2006).

    Article  PubMed Central  Google Scholar 

  45. 45

    Lee, Y. C. et al. Gray-scale and color Doppler sonographic findings of epiploic appendagitis. J. Clin. Ultrasound 29, 197–199 (2001).

    CAS  Article  PubMed Central  Google Scholar 

  46. 46

    Hanson, J. M. & Kam, A. W. Paracolic echogenic mass in a man with lower abdominal pain. Is epiploic appendagitis more common than previously thought? Emerg. Med. J. 23, e17 (2006).

    CAS  Article  PubMed Central  Google Scholar 

  47. 47

    Danse, E. M. et al. Epiploic appendagitis: color Doppler sonographic findings. Eur. Radiol. 11, 183–186 (2001).

    CAS  Article  PubMed Central  Google Scholar 

  48. 48

    Sirvanci, M., Balci, N. C., Karaman, K., Duran, C. & Karakas, E. Primary epiploic appendagitis: MRI findings. Magn. Reson. Imaging 20, 137–139 (2002).

    Article  PubMed Central  Google Scholar 

  49. 49

    Mclure, M. J., Khalli, K., Sarrazin, J. & Hanbidge, A. Radiological features of epiploic appendagitis and segmental omental infarction. Clin. Radiol. 56, 819–827 (2001).

    Article  Google Scholar 

  50. 50

    Lien, W. C. et al. Epiploic appendagitis mimicking acute cholecystitis. Am. J. Emerg. Med. 22, 507–508 (2004).

    Article  PubMed Central  Google Scholar 

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W. J. Schnedl, R. Krause and R. W. Lipp researched data for the article and discussed the content of the manuscript together with E. Tafeit and S. J. Wallner-Liebmann. The article was written by W. J. Schnedl, M. Tillich and S. J. Wallner-Liebmann. All authors contributed equally to review and/or editing of the manuscript before submission.

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Correspondence to Wolfgang J. Schnedl.

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Schnedl, W., Krause, R., Tafeit, E. et al. Insights into epiploic appendagitis. Nat Rev Gastroenterol Hepatol 8, 45–49 (2011). https://doi.org/10.1038/nrgastro.2010.189

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