IS Case 164: Appendagitis Epiploica (Epiploic Appendagitis)

Brady Huang, MD


Imaging Sciences URMC 2008
Publication Date: 2009-05-21

History

Patient is a 69-year-old male with a 4 day history of sudden onset left lower quadrant pain. The patient was afebrile and without an elevated white count. He was given one dose of antibiotics in the Emergency Department, but antibiotics were subsequently stopped. The patient recovered after 3 days of conservative management including intravenous morphine.

Findings

Pericolonic, oval-shaped lesions with fat attenuation and periappendageal fat stranding in the left lower quadrant.

Diagnosis

Appendagitis Epiploica (Epiploic Appendagitis)

Discussion

Epiploic appendages arise from the serosal surface of the colon, attached by a vascular stalk. The are typically 0.5 to 5 cm in length and have the largest density around the sigmoid colon. They are typically only seen on CT when inflamed or surrounded by fluid/ascites. Torsion of the epiploic appendages results in venous or arterial occlusion leading to ischemia and acute epiploic appendagitis. This occurs in adults, usually in the 4th and 5th decades (although reported between 12 and 82 years) and predominately in men. Clinically it may mimic acute appendicitis and diverticulitis, with acute onset pain usually in the left lower quadrant. The pain rarely migrates from the periumbilical region as in appendicitis. The patients may have a temperature elevation, but rarely above 83.3 C and the average leukocyte count is 12,000 cells/mm3, with one-third of cases less than 10,000. Appendicitis patients are more likely to experience anorexia, nausea, vomiting, and a more robust fever and leukocyte response. Most importantly, epiploic appendagitis is usually a self-limited disease that is managed conservatively with observation, antiemetics, and analgesics. A presumed diagnosis of epiploic appendagitis may be made on the clinical presentation and confirmatory imaging by CT.

The CT features of acute epiploic appendagitis are that of an oval lesion 1.5 to 3.5 cm in diameter, with attenuation similar to fat, surrounding infiltrative changes, and abutting the anterior sigmoid colon wall. The sites of involvement in decreasing frequency are the sigmoid colon, descending colon, and ascending colon. There may be secondary thickening of the adjacent parietal peritoneum and colon wall. There may be a central area of high attenuation representing venous thrombosis, which aides in the diagnosis. Although clinical symptoms usually resolve in less than 2 weeks, the CT findings persist longer. Follow-up CT findings range from no change, to decrease in size, to residual soft-tissue attenuation. Entities that may mimic epiploic appendagitis on CT include acute omental infarction, mesenteric panniculitis, a fat-containing tumor, diverticulitis, and appendicitis.

References

  1. Rao PM, Wittenberg J, Lawrason JN. Primary epiploic appendagitis: evolutionary changes in CT appearance. Radiology. 1997 Sep;204(3):713-7. [PMID: 9280248]
  2. Singh AK, Gervais DA, Hahn PF, Rhea J, Mueller PR. CT appearance of acute appendagitis. AJR Am J Roentgenol. 2004 Nov;183(5):1303-7. [PMID: 15505294]
  3. Singh AK, Gervais DA, Hahn PF, Sagar P, Mueller PR, Novelline RA. Acute epiploic appendagitis and its mimics. Radiographics. 2005 Nov-Dec;25(6):1521-34. [PMID: 16284132]
  4. Vinson DR. Epiploic appendagitis: a new diagnosis for the emergency physician. Two case reports and a review. J Emerg Med. 1999 Sep-Oct;17(5):827-32. [PMID: 10499697]

4 images