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Year : 2006  |  Volume : 16  |  Issue : 4  |  Page : 447-449
Ct diagnosis of epiploic appendagitis-a case report


Teleradiology Solutions, No. 2, Regent Place, Whitefield Main Road, Bangalore - 560066, India

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Date of Submission22-Aug-2005
Date of Acceptance10-Aug-2006
 

Keywords: Appendices epiploicae, epiploic appendagitis, CT scan

How to cite this article:
Bhat P A, Sridhar P G, Sreenivasan N, Kalyanpur A. Ct diagnosis of epiploic appendagitis-a case report. Indian J Radiol Imaging 2006;16:447-9

How to cite this URL:
Bhat P A, Sridhar P G, Sreenivasan N, Kalyanpur A. Ct diagnosis of epiploic appendagitis-a case report. Indian J Radiol Imaging [serial online] 2006 [cited 2019 Aug 20];16:447-9. Available from: http://www.ijri.org/text.asp?2006/16/4/447/32242

   Introduction Top


Primary epiploic appendagitis is a relatively rare condition in which torsion and inflammation of an epiploic appendix result in localized abdominal pain. The inflammation of epiploic appendix may also be secondary to inflammation of adjacent organs e.g. diverticulitis, appendicitis and cholecystitis. In the past, the diagnosis has usually been made at surgery as the condition is generally mistaken for acute appendicitis or sigmoid diverticulitis. However, the condition can be managed conservatively with the use of analgesic drugs only, and clinical evolution is uneventful. CT allows a non-invasive diagnosis, thus avoiding unnecessary surgery.


   Case report Top


We report two cases of epiploic appendagitis (EA) diagnosed on CT scan.

The first patient was a 45-year-old male who presented with a history of right lower quadrant pain, elevated leukocyte count and mild fever. On clinical examination there was tenderness over the right iliac fossa. A clinical diagnosis of appendicitis was made and the patient was subjected to CT scan of the abdomen and pelvis with oral and intravenous contrast. Contrast enhanced CT scan showed an approximately 1 cm oval fat density lesion adjacent to cecum with associated perilesional fat stranding and adjacent bowel (cecal) wall thickening [Figure - 1]a. There was a central linear high attenuation structure within the fat density lesion [Figure - 1]b. The appendix was within normal limits. No other abnormality was detected.

The second patient, a 50-year-old male presented with left lower quadrant pain and tenderness. A provisional diagnosis of diverticulitis was made and the patient was also subjected to CT scan of the abdomen and pelvis with IV contrast.

The CT scan demonstrated a similar appearing fat density lesion along the antimesenteric border of the sigmoid colon [Figure - 2] with associated perilesional fat stranding, however without associated bowel wall thickening. The central high attenuation structure was again seen.

In both the cases a diagnosis of epiploic appendagitis was made. Both patients were treated conservatively with antibiotics and analgesics and had an uneventful recovery.


   Discussion Top


Appendices epiploicae are adipose structures protruding from the serosal surface of the colon and have no known function. Epiploic appendices are located on the antimesenteric border of the colon, mainly the cecum and the sigmoid colon. They can be seen with cross-sectional imaging if there is intraperitoneal contrast material, ascites, or blood surrounding the colonic wall. Normal appendices epiploicae appear as lobulated masses of pericolic fat, usually 2-5 cm long and 1-2 cm thick, the longest are usually in the sigmoid colon. Their blood supply is from the superior and inferior mesenteric arteries, with drainage into the corresponding veins.

Epiploic appendagitis is a rare inflammatory condition that results from torsion or spontaneous venous thrombosis of one of the appendices epiploicae [1]. Diseases of the epiploic appendages are most common in the 3rd and 4th decades of life [2]. Their inflammation may result from various pathologic processes that can originate locally or extend from adjacent viscera. Complications related to the epiploic appendages include intestinal obstruction secondary to adherence to small bowel, diverticulitis, torsion and infarction [3],[4],[5]. Long-standing infarction may cause amputation of the appendage, which may then appear as a loose calcified peritoneal body.

Disorders of appendices epiploicae are often manifested by nonspecific clinical signs and symptoms The right iliac fossa is the most common site for pain and tenderness, even if the sigmoid colon is the affected site. The diagnosis is rarely made clinically and historically the diagnosis was made only at surgery. With the advent of imaging modalities like CT scan and sonography which demonstrate characteristic findings of Epiploic appendagitis , a preoperative diagnosis can be made with high level of confidence so as to prevent unnecessary surgery for this self limiting condition.

CT characteristics of EA:

(A) Oval or round shape, fat attenuation lesion (but higher in attenuation than uninvolved fat) along the anti-mesenteric border of the colon, with periappendiceal fat stranding.

(B) A well circumscribed hyperattenuated rim that surrounds the mass and represents the inflamed visceral peritoneal lining [6].

(C) There may be associated bowel wall thickening/compression. Very rarely a central high-attenuation "dot" can be identified within the inflamed appendage [7]. The later finding corresponds to the thrombosed vein [8]

(D) The paracolonic inflammatory changes are disproportionately more severe than the mild reactive thickening of the adjacent colonic wall [6]

The appendices epiploicae can be identified by sonography only when surrounded by fluid, their shape may be similar to that of peritoneal tumors. US features of epiploic appendagitis include small, ovoid echogenic mass that is not compressible, located anterolateral to the right colon and anteromedial to the left colon [7].

 
   References Top

1.Pines B, Rabinovitch J, Biller SB. Primary torsion and infarction of the appendices epiploicae. Arch Surg 1941; 42: 775-87.   Back to cited text no. 1    
2.Desai HP, Tripodi J, Gold BM, Burakoff R. Infarction of an epiploic appendage: review of the literature. J Clin Gastroenterol 1993; 16:323-5.  Back to cited text no. 2  [PUBMED]  
3.Ghahremani GG, White EM, Hoff FL, et al. Appendices epiploicae of the colon: radiologic and pathologic features. Radiographics 1992; 12:59-77.   Back to cited text no. 3  [PUBMED]  
4.Romaniuk CS, Simpkins KC. Case report. Pericolic abscess secondary to torsion of an appendix epiploica. Clin Radiol 1993; 47:216-7.   Back to cited text no. 4    
5.Carmichael DH, Organ CH Jr. Epiploic disorders. Conditions of the epiploic appendages. Arch Surg 1985; 120:1167-72.   Back to cited text no. 5    
6.Radiographics 2004;24:703-715.Jose M.Pereria, MD, Claude B, Sirlin, MD, Pedro S, Pinto MD, R. Brooke Jeffrey MD, Damien L, Stella MD, Giovanna Casola MD.  Back to cited text no. 6    
7.Radiology 1997; 204: 713-717. PM Rao, J Wittenberg and JN Lawrason.  Back to cited text no. 7    
8.Rioux M, Langis P. Primary epiploic appendagitis: clinical, US, and CT findings in 14 cases. Radiology 1994;  Back to cited text no. 8    

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Correspondence Address:
P A Bhat
Consultant Radiologist, Teleradiology Solutions, No. 2, Regent Place, Whitefield Main Road, Bangalore - 560066
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0971-3026.32242

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