Teaching Case

Isolated left lower abdominal pain

A 31-year-old woman was admitted to the emergency department with a left lower abdominal pain. There was no vomiting diarrhea constipation or fever. The pain of 24 hours duration was sudden in onset, well localised by the patient. On physical examination, this point was painfull after deep palpation. No other physical findings were evident. Laboratory values were unremarkable. Plain abdominal radiograph was normal. The patient underwent an abdominal CT scan without contrast medium (Fig.1)

Primary epiploic appendagitis is a rare inflammatory abdominal process due to an ischemic infarction of an epiploic appendage. This is an adipose structure from the serosal surface of the colon, which could be affected by various complication and spontaneous torsion is one of them. Patient with primary epiploic appendagitis characteristically present with an abrupt onset of focal abdominal pain. This pain appears with mild or absent additional findings at history and physical examination. Laboratory evaluation is normal despite a moderate increasing white blood cell count. CT scan has characteristic patterns that permit correct diagnosis which is often mistaken and usually diagnosed at surgery. CT scan shows a fat oval paracolic anterior or anterolateral mass separated by a thick rim from the normal fat and with an higher attenuation. A moderate mass effect on the adjacent colon is possible like a thickened adjacent peritoneum. Symptoms usually resolved gradually with analgesics.