The Diagnostic Dilemma of Primary Epiploic Appendagitis and How to Establish a Diagnosis

Abstract

Primary epiploic appendagitis (PEA) is a relatively uncommon, non-surgical situation that clinically mimics other conditions requiring surgery. In PEA, torsion and inflammation of an epiploic appendix results in localized abdominal pain. This condition may be clinically misdiagnosed, resulting in unnecessary surgical intervention. We report the unusual case of a healthy 44-year-old man, who presented to the 417 NIMTS Military Veterans' Fund Hospital of Athens with non-migratory left lower quadrant abdominal pain, which had started 24 hours before admission. The patient described a constant, sharp, non-radiating pain. He had no symptoms of nausea, vomiting, constipation, diarrhea, or fever. Abdominal examination showed focal abdominal tenderness with slight rebound tenderness. The diagnosis of PEA of the sigmoid colon was made based on the findings of an abdominal contrast computed tomography (CT). The key findings of CT were an oval lesion with a maximum diameter of 2.4 cm, with fat attenuation, and a circumferential hyperdense ring located adjacent to the sigmoid colon. This case is presented to highlight the clinical characteristics of PEA, which may help clinicians to overcome this diagnostic dilemma and reach the correct diagnosis.

Abdominal pain – learning when not to intervene!

“…As epiploic appendages are widespread in colon, EA can occur anywhere; however, the most common sites are rectosigmoid junction (57%), ileocecal region (26%), ascending colon (9%), transverse colon (6%), and descending colon (2%) (10). EA has been reported in up to 7% of patients suspected of diverticulitis and in up to 1% of patients suspected of appendicitis (3, 6, 10). …”

“…Primary EA occurs due to localized sterile inflammation of epiploic appendages because of torsion or spontaneous venous thrombosis (3, 6, 10). Secondary EA, on the contrary, occurs due to adjacent disease process such as appendicitis, diverticulitis, cholecystitis, and inflammatory bowel disease (3, 10).…”

“…Diagnosis is usually made by contrast-enhanced CT scan or ultrasonography of abdomen (1–4, 6–10, 12). Ultrasonography findings most commonly include a solid, non-compressible, hyperechoic oval mass with a hypoechoic rim (1, 6, 7, 9, 12). The pathognomic finding on CT abdomen is a hyperattenuated 2–3 cm oval-shaped fat density with paracolonic inflammation and fat stranding (3–12), as in our patient.…”

“…Epiploic appendages are 50–100 pedunculated, fat-filled outpouchings of the colon from the cecum to the rectosigmoid junction (1–6). Each appendage is supplied by one or two arterioles and drained by a single venule (4–8).…”

“…Each appendage is supplied by one or two arterioles and drained by a single venule (4–8). Ischemia, infarction, or torsion of the appendage results in epiploic appendagitis (EA) which can mimic acute appendicitis, diverticulitis, cholecystitis, or acute gynecological disorder depending on the site of involvement of epiploic appendages (1, 3, 6, 9). EA is a rare cause of abdominal pain; however, it should always be kept in the differential diagnosis of abdominal pain as it may help avoid unnecessary hospital admissions and interventions.…”