Epiploic Appendagitis

Clinical History: A 42-year-old woman with no significant past medical history presented with three days of sharp left sided abdominal pain with associated nausea and anorexia. Her surgical history was remarkable for a right oophorectomy, vaginal hysterectomy, and chest wall mass removal. She was afebrile without tachycardia.

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Figure 1

Her physical examination was remarkable for localized tenderness in the left lower quadrant. Her labs revealed a normal white blood cell count (5.8 K/ul) with normal differential. Computed tomography of the abdomen/pelvis was remarkable for a region of inflammation in the left mid quadrant with central fat and peripheral enhancement (Figure 1) consistent with a diagnosis of epiploic appendagitis. She was admitted for supportive care and discharged after resolution of symptoms without incident.

Epiploic appendagitis is an uncommon cause of abdominal pain that is self-limiting (1). Found only on the exterior surface of the colon, epiploic appendages are adipose sacs supplied by a pair of arteries and a single vein (2). The venous supply is susceptible to torsion, kinking, and stretching, ultimately leading to thrombosis and infarction (3). The left sided distribution of pain correlates with the fact that epiploic appendages on the sigmoid colon are typically the largest and most susceptible to torsion. The computed tomography appearance of epiploic appendagitis is classic and typically demonstrates a pericolonic ovoid fatty mass with hyper-attenuating rim and surrounding fat stranding (3, 4). A “central dot sign” can also occur with thrombosis of the epiploic vein (1, 2). Treatment for epiploic appendagitis is supportive as the disease process itself is self-limited.

References:
1. Chen JH, Wu CC, Wu PH. Epiploic appendagitis: An uncommon and easily misdiagnosed disease. Journal of Digestive Diseases 2011: 12(6); 448-52.
2. Sign AK, Gervais DA, Hahn PF, Sagar P, Mueller PR, Novelline RA. Acute epiploic appendagitis and its mimics. Radiographics 2005: 25(6); 1521-34.
3. van Brenda Vriesman AC, de Mol van Otterloo AJ, Puylaert JB. Epiploic appendagitis and omental infarction. European Journal of Surgery 2001: 167(10); 723-7.
4. Hasbahceci M, Erol C, Seker M. Epiploic appendagitis: Is there need for surgery to confirm diagnosis in spite of clinical and radiological findings? World Journal of Surgery 2012: 36(2); 441-6.

Paul E. Palmer, III, BS; Neil R. Desai, DO; Peter A. Walker, MD - Department of Surgery, University of Texas Medical School at Houston, Houston, Texas; and Uwe M. Fischer, MD, PhD, and Shinil K. Shah, DO - Department of Surgery, University of Texas Medical School at Houston, Houston, Texas and Michael E. DeBakey Institute for Comparative Cardiovascular Science and Biomedical Devices, Texas A&M University, College Station, Texas

Figure Legends:
Figure 1: CT scan of the abdomen/pelvis demonstrating a region of inflammation in the left mid quadrant with central fat and peripheral enhancement consistent with a diagnosis of epiploic appendagitis.