Clinical History
31 years-old man was admitted to hospital with right lower quadrant pain.
Imaging Findings
A 31 year old male patient presented with right lower quadrant pain for the last 8 hours. In the physical examination there was tenderness in the left lower quadrant and left flank. In the laboratory results: WBC 7400, Hb 15.5gr/dl, Htc 43.9mg/dl, serum glucose 87mg/dl, liver tests normal, T. protein and albumin normal, serum amylase 71.
Contrast enhanced CT was done and the diagnosis of primary epiploic appendagitis was made on the basis of radiological findings (Fig 1). After 20 days, the inflammation regressed and the size of inflamed appendix epiploica decreased (Fig 2).
Discussion
TERMINOLOGY AND EPIDEMIOLOGY:
A rare benign self-limiting inflammatory process of the colonic epiploic appendices. Epiploic appendices correspond to peritoneum covered fatty structures about 2-5 cm long (Fig 3). They are about 100 in number and distributed in two rows along the free tenia and tenia omentalis, from the cecum to the sigmoid colon. They are largest along the descending and sigmoid colon and smallest along the transverse colon. Their somewhat precarious blood supply from colic arterial branches and their pediculated nature and great mobility are factors increasing the susceptibility of torsion and infarction. The involvement of sigmoid and cecal appendices are more frequent, probably because of their larger size. When torsion, ischemia or inflammation occurs spontaneously, the condition is termed "primary epiploic appendagitis." Secondary epiploic appendagitis is caused by inflammation of adjacent organs, as in diverticulitis, appendicitis and cholecystitis. The true incidence of EA is unknown. However it is more frequently diagnosed now due to the wider use of imaging evaluation of patients presenting with acute abdominal pain.
Patogenesis is spread into torsion and inflammation (73%), hernia incarceration, (18%), intestinal obstruction (8%), and intraperitoneal loose body (<1%).
There is a predominance in men. Age distribution is mainly 4th-5th decades of life.
RADIOLOGIC FINDINGS:
On US images, the characteristics of acute epiploic appendagitis is an oval non-compressible hyperechoic mass at the site of maximum tenderness, adjacent to the colon, with no central blood flow depicted on colour Doppler US images. The most common CT feature in acute epiploic appendagitis is an oval lesion less than 5 cm in diameter (typical diameter range 1.5-3.5 cm) that has attenuation equivalent to that of fat, that abuts the anterior colonic wall, and that is surrounded by inflammatory changes. Thickening of the parietal peritoneum, secondary to the spread of inflammation, also may be observed. The wall of the colon may be thickened but is most often normal in thickness. Although the presence of a central area of high attenuation due to venous thrombosis is useful for diagnosis, the absence of this feature does not preclude a diagnosis of acute epiploic appendagitis. T1- and T2-weighted MR images show a focal lesion with the signal intensity of fat. Contrast-enhanced T1-weighted MR images show an enhancing rim around the oval fatty lesion.
For differential diagnosis, acute diverticulitis, acute appendicitis, acute epiploic appendagitis, acute omental infarction, sclerosing mesenteritis, primary tumours (liposarcoma, exophytic angiomyolipoma and dermoid) or metastasis that involves the mesocolon) have to be considered.
The therapeutic approach is conservative with oral anti-inflammatory medication.
Differential Diagnosis List
Primary epiploic appendagitis
Final Diagnosis
Primary epiploic appendagitis
