Clinical History
A 46-year-old man was admitted to the emergency department due to a sudden onset of pain, localised in the left lower abdomen. It was associated with low grade fever of 38.5 degrees Celsius. Laboratory values showed neutrophilic leucocytosis (14500) and mildly raised C Reactive protein (2.7mg/dl).
Imaging Findings
Plain abdominal radiograph was considered normal. Abdominal and renal ultrasound were unremarkable. The patient underwent an abdominal CT examination without contrast medium.
Unenhanced CT of the abdomen and pelvis demonstrated a pedunculated oval-shaped mass, adjacent to the anterior wall of the sigmoid colon, with a fatty central core surrounded by a peripheral dense rim and focal stranding of the fat. Central high-attenuating “dot” was also seen within the appendage, which might correspond to a thrombosed draining vein.
The colonic wall was not thickened or inflamed. There was no evidence of diverticular disease of the colon. No other abnormalities such as free gas or fluid were identified. The imaging findings were consistent with epiploic appendagitis. Patient had clinical improvement with oral analgesic therapy.
Discussion
Epiploic appendagitis is a benign self-limited inflammatory process involving the colonic epiploic appendices. It is a rare cause of abdominal pain and is thought to be the result of torsion or spontaneous vascular thrombosis of epiploic appendices.
Epiploic appendices are fatty outpouchings structures of serosal surface of the colon, in the antimesenteric border, measuring about 2 to 5 cm. They are about 100 in number, distributed from the caecum to the sigmoid colon and are absent in the appendix and the rectum. Their somewhat precarious blood supply from colic arterial branches, their pedunculated nature and great mobility are factors for increasing the susceptibility of torsion and infarction.
The common location of epiploic appendagitis is rectosigmoid junction (57%), ileocaecal region (26%), ascending colon (9%), transverse colon (6%), and descending colon (2%). Depending on the location, age and gender, it can simulate various acute disease processes, such as diverticulitis, appendicitis, renal colic, acute bowel inflammatory disease, ovarian torsion or perforated colon cancer ulcer.
Patients with primary epiploic appendagitis typically present with a sudden onset of focal abdominal pain, sometimes with fever. Laboratory values show increased white blood cell count. CT is the gold standard examination and gives the definitive diagnosis. Epiploic appendices are normally invisible on CT. The typical CT findings of epiploic appendagitis include an ovoid pericolic mass with fat density, surrounded by a hyperdense ring that represents an inflamed peritoneal covering of the appendage and loco-regional fat stranding representing involving inflammatory changes. A hyperdense central "dot" is present in approximately 30% of cases and represents a thrombosed central vein. Treatment is conservative and it is usually resolved with analgesics.
Differential Diagnosis List
Epipoic appendagitis
Diverticulitis
Appendicitis
Renal colic
Acute bowel inflammatory disease
Ovarian torsion
