CASE

A 50-year-old female presents to the emergency department complaining of two days of gradually worsening left lower quadrant abdominal pain.  She endorses anorexia and multiple episodes of vomiting. She is slightly tachycardic, but afebrile.  She is noted to have tenderness to palpation to the left lower quadrant but no significant rebound or guarding. Given her presentation, diverticulitis becomes the leading differential diagnosis, although renal colic is also a possibility. For that reason a non-contrast CT scan of the abdomen/pelvis is ordered for further evaluation:

DIAGNOSIS

Epiploic appendagitis (EG), a known mimic of appendicitis, as well as diverticulitis.[i]

DISCUSSION

As seen above, the classic CT imaging demonstrates a 2 to 3 cm oval-shaped paracolic mass with associated periappendageal fat stranding.[ii] If the EG is caused by thrombosis of the central drainage vein, a central dot may be seen within the inflamed appendage.[iii]

EG is caused by an ischemia to the epiploic appendage, which is normal peritoneal fat suspended from the anti-mesenteric colon surface. It occurs most often by torsion of the appendage or thrombosis of the appendageal central draining vein.

The mainstay of treatment for most patients is conservative management with oral NSAIDs or opiates for several days until pain resolves. Resolution of symptoms can be expected between 3-14 days. Most patients can be safely discharged and antibiotics are not required.[i] Rarely, some patients may require surgery for severe pain or if they develop complications such as bowel obstruction, abscess or intussusception.[ii]

TAKE-AWAYS

• EG is a relatively uncommon, but benign cause of abdominal pain. Emergency providers should be aware of this diagnosis and recognize findings on CT imaging.

• Treatment is oral pain control.

Faculty Reviewer: Dr. Robert Tubbs

References

[i] Schnedl WJ, Krause R, Tafeit E, et al. Insights into epiploic appendagitis. Nat Rev Gastroenterol Hepatol 2011; 8:45.

[ii] Rao PM, Wittenberg J, Lawrason JN. Primary epiploic appendagitis: evolutionary changes in CT appearance. Radiology 1997; 204:713.

[iii] Rioux M, Langis P. Primary epiploic appendagitis: clinical, US, and CT findings in 14 cases. Radiology 1994; 191:523.

[iv] Sangha S, Soto JA, Becker JM, Farraye FA. Primary epiploic appendagitis: an underappreciated diagnosis. A case series and review of the literature. Dig Dis Sci 2004; 49:347.

[v] Puppala AR, Mustafa SG, Moorman RH, Howard CH. Small bowel obstruction due to disease of epiploic appendage. Am J Gastroenterol 1981; 75:382.