1511 Epiploic Appendagitis After Rigorous Exercise in a Woman: An Easily Misdiagnosed Cause of Acute Abdomen

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INTRODUCTION: Acute abdominal pain can be a surgical emergency. However, benign etiologies, such as epiploic appendagitis (EA), can present with similar symptoms. We report a case of an otherwise healthy woman, on oral contraceptives (OCP), presenting with severe abdominal pain related to epiploic appendagitis. Timely recognition of this condition is important to avoid misdiagnosis and unnecessary surgical interventions. CASE DESCRIPTION/METHODS: A 44-year-old woman with a past medical history of ovarian cyst and BMI 25 presented to the Emergency Department with a three-day history of sharp left lower quadrant (LLQ) pain. Patient reported that she started a vigorous aerobic exercise regimen 6 weeks before. Only medication was norgestimate-ethinyl estradiol for contraception. Vital signs normal. Physical exam showed tender LLQ without rebound tenderness or rigidity. Initial testing including complete blood count, basic metabolic panel, pregnancy test, urinalysis, and vaginitis panel were unremarkable. Given worsening pain, CT scan of abdomen and pelvis with contrast was obtained showing an encapsulated oval, pericolonic fatty nodule adjacent to the sigmoid colon, with surrounding fat stranding consistent with EA. Patient was discharged home with conservative pain management. Her OCP was discontinued. She had no symptom recurrence within a 3-year period. DISCUSSION: EA is an uncommon cause of acute abdominal pain that mimics serious medical or surgical emergencies such as acute diverticulitis, appendicitis, or, gynecological emergencies such as ruptured ectopic pregnancy. It is, generally, a self-limited ischemic infarction involving the epiploic appendices, which are normal outpouching fat of the lower colon and rectum. EA can be divided into primary versus secondary. The primary form is caused by either torsion or spontaneous venous thrombosis of an epiploic appendage central draining vein. It commonly occurs in men aged 20–50. Risk factors include obesity, hernia, and rigorous exercise. Secondary form is related to inflammation of adjacent organs. Although our patient does not match the typical profile for EA, rigorous exercise and probably OCP usage, a risk factor for thromboembolic phenomena, may have triggered this episode. Diagnosis of EA is by imaging via ultrasound or CT scan, and complete resolution typically occurs within two weeks with conservative management. Prompt identification of EA is essential in patients at risk, to avoid unnecessary surgical procedures.