Epiploic appendagitis: pathogenesis, clinical findings and imaging clues of a misdiagnosed mimicker

Abstract

Primary epiploic appendagitis (PEA) is a rare and frequently underdiagnosed cause of acute abdominal pain. PEA most commonly affects obese, male patients in the 4th and 5th decade of life. Clinical presentation includes acute, localized, non-migrating pain without fever, nausea, vomiting or diarrhea and the laboratory workup is usually within normal limits. PEA is commonly mistaken as other more severe causes of acute abdominal pain, such as diverticulitis, acute appendicitis or cholecystitis and thus patients undergo unnecessary diagnostic and therapeutic procedures. The emergence of computerized tomography (CT) as the gold standard imaging test in diagnostic dilemmas of acute abdominal pain has resulted in increased recognition and diagnosis of PEA. Upon confirmation, PEA is considered a self-limiting disease and is managed conservatively with analgesics, occasionally combined with nonsteroidal anti-inflammatory drugs (NSAIDS).Persistence of symptoms or recurrence mandate the consideration of surgical management with laparoscopic appendage excision as the definitive treatment. We review the current literature of PEA, with a focus on clinical and imaging findings, in order to raise awareness about this frequently misdiagnosed entity.

Epiploic Appendagitis Masquerading as Acute Appendicitis: A Report of Two Cases

“…These were anatomically first described in 1543 by Vesalius, but their clinical significance was not known until 1853 when a source of free intra-peritoneal loose bodies was questioned, and Virchow postulated that their detachment from the bowel surface might be the source [ 2 , 4 ]. Varying in length from 0.5 to 5 cm, epiploic appendages have one to two arterioles and a venule derived from vasa recti to form a vascular stalk.…”

“…Primary EA presenting as a clinical entity due to de novo venous thrombosis of the draining venule was first described in 1956 by Lynn [ 9 ]. Inflammation of the adjacent organs like appendicitis, diverticulitis or cholecystitis can cause secondary EA [ 4 ].…”

“…The incidence of EA ranges from 2% to 7% in cases of provisional diagnosis of acute diverticulitis and 0.3% to 1% in suspected acute appendicitis cases [ 10 ]. Acute EA of the appendix, which is the inflammation of the epiploic appendages close to the vermiform appendix, is even rarer accounting for only 3% of all the EA cases [ 4 ], often masquerading as acute appendicitis. Most reports suggest male predominance [ 5 , 11 , 12 ] whereas some reports mentioned that it is more prevalent in female gender [ 13 ], but both our cases were females.…”

Bilateral Epiploic Appendagitis: A Rather Benign but Diagnostically Challenging Cause of Acute Abdominal Pain

“…EA occurs predominantly in males in the fourth and fifth decade of life, with an approximate incidence of 8-9 cases per million individuals per year [3]. There have been some case reports in pediatric and geriatric age groups as well [4]. EA has been described more frequently among obese and overweight individuals.…”

“…Epiploic appendagitis usually presents with abdominal pain and perfectly mimics with other surgically managed conditions of serious nature. In the past, EA was also considered as a surgically treated pathology and often diagnosed during laparotomy [4,7]. Advent of the latest radiologic imaging modalities, especially with the routine use of contrast-enhanced CT scan in patients with abdominal pain has resulted in increased recognition and diagnosis of EA, making it a significant entity for radiologists as well [8].…”