Peer Reviewed

Photoclinic

Epiploic Appendagitis Mimicking Diverticulitis

Mohammed Hassan-Ali, MD, MSc, Mohemmad Abbas, MD, and Ahmed Raziuddin, MD

Volume 56 - Issue 2 - February 2016

Authors:
Mohammed Hassan-Ali, MD, MSc; Mohemmad Abbas, MD; and Ahmed Raziuddin, MD

Citation:
Hassan-Ali M, Abbas M, Raziuddin A. Epiploic appendagitis mimicking diverticulitis. Consultant. 2016;56(2):180-181.

 

A 25-year-old man presented to the emergency department after having been referred by his primary care provider (PCP). The patient presented with a 4-day history of sudden pain in the left lower quadrant, leading to the PCP’s initial diagnosis of diverticulitis. During the history, the patient described sharp, severe, nonradiating pain, which was aggravated by eating, movement, and deep breathing. The patient denied nausea, vomiting, change in bowel movements, fever, or fatigue, but he had noticed a loss of appetite. Previous medical and family history was noncontributory. Social history revealed that he was a current cigarette smoker.

Physical examination. Vital signs upon examination were within normal limits, except for a fever of 37.4°C. Physical examination of revealed an obese man (body mass index, 39.2 kg/m2) in mild distress. Abdominal examination revealed a soft and tender left flank anteriorly, with voluntary guarding and rebound. Bowel sounds were hyperactive. The rest of the physical examination findings were unremarkable.

Diagnostic tests. Initial laboratory studies included a complete blood count (CBC) with differential, a comprehensive metabolic panel, serum amylase level, serum lipase level, and urine dipstick testing. Key findings included elevated alanine aminotransferase (91 U/L; reference range, 0-41 U/L) and elevated aspartate transaminase (49 U/L; reference range, 0-37 U/L). Serum amylase and lipase levels were within normal limits, as were CBC findings. Urine dipstick test was positive for trace of occult blood, raising the possibility of nephrolithiasis and renal colic as differential diagnoses.

Abdominal computed tomography (CT) scan with contrast revealed a fatty liver and a 7-mm polyp in the gallbladder, but no diverticula (Figure). The scan also showed edematous and inflammatory changes associated with the fat stranding, anterior to the mid-descending colon, consistent with epiploic appendagitis.

Outcome of the case. The patient was given intravenous piperacillin/tazobactam, vancomycin, pantoprazole, and morphine for pain relief and potential bacterial infection, and he was placed on nothing-by-mouth status. He subsequently was admitted for observation awaiting surgical consult. No surgical intervention was needed, however, as the patient’s condition resolved without it. Because the patient remained clinically stable, he was discharged on a low-residue diet with instructions to follow-up with his PCP after 1 week.

Discussion. Epiploic appendagitis is a rare phenomenon that can be confused with acute appendicitis (up to 7% of the time) or diverticulitis (up to 1% of the time).1 It is an inflammatory condition that affects the epiploic appendage of the colon.2 It is believed that torsion of the appendages or thrombosis of the venous outflow leads to inflammation and/or ischemia.2

These epiploic appendages, which are numerous near the transverse and sigmoid colon, are small outpouchings of the colonic surface.3 The appendages house branches of the circular artery and veins that supply the segment of the colon that they encompass. They are thought to provide some assistance in absorption or cushioning.4

While the appendages vary in shape and size, they are largest and most numerous in obese persons.5 Epiploic appendagitis affects men 4 times more often than women.3 The commonly affected regions of the colon are the rectosigmoid junction (57%) and the ileocecal region (26%).6

Symptoms include localized abdominal pain, rebound tenderness, and mild fever, but no significant indicators in laboratory test results.2 Diagnosis is made by ultrasonography or CT.2 CT scans will show thick, fat-dense structure, inflammation, and a central, hyperdense dot suggesting thrombosis.6 Epiploic appendagitis is self-limiting and can be managed with prophylactic antibiotics, symptomatic pain management, and admission for observation.7 Surgical intervention is not required.

References:

  1. Singh AK, Gervais DA, Hahn PF, Rhea J, Mueller PR. CT appearance of acute appendagitis. AJR Am J Roentgenol. 2004;183(5):1303-1307.
  2. Subramaniam R. Acute appendagitis: emergency presentation and computed tomographic appearances. Emerg Med J. 2006;23(10):e53.
  3. Schnedl WJ, Krause R, Tafeit E, Tillich M, Lipp RW, Wallner-Liebmann SJ. Insights into epiploic appendagitis. Nat Rev Gastroenterol Hepatol. 2011; 8(1):45-49.
  4. Pines B, Rabinovitch J, Biller SB. Primary torsion and infarction of the appendices epiploicae. Arch Surg. 1941;42(4):775-787.
  5. Ghahremani GG, White EM, Hoff FL, Gore RM, Miller JW, Christ ML. Appendices epiploicae of the colon: radiologic and pathologic features. Radiographics. 1992;12(1):59-77.
  6. Almeida AT, Melão L, Viamonte B, Cunha R, Pereira JM. Epiploic appendagitis: an entity frequently unknown to clinicians—diagnostic imaging, pitfalls, and look-alikes. AJR Am J Roentgenol. 2009;193(5):1243-1251.
  7. Singh AK, Gervais DA, Hahn PF, Sagar P, Mueller PR, Novelline RA. Acute epiploic appendagitis and its mimics. Radiographics. 2005;25(6):1521-1534.