Epiploic Appendagitis: A Possible Work-Related Etiology

Abstract

To the Editor: Two patients were recently evaluated and treated for acute onset abdominal pain, which occurred while performing relatively heavy physical activity. The patients were sent by different companies, to separate occupational medicine clinics. One of these patients, a 44-year-old man, was shoveling concrete when symptoms occurred. The other patient, a 30-year-old man, was lifting a heavy palette while twisting and then throwing it when pain occurred in the abdomen. Although uncomfortable, no vomiting, fever, or toxicity was noted in either case. A finding of tenderness to palpation of the epigastric area, right and left lower abdominal quadrants was noted in the 44-year-old patient. The diagnosis of “abdominal pain” and “possible ventral hernia” was made. The 30-year-old patient was noted to have tenderness, and was “very painful” in the left lower abdominal quadrant and the left inguinal region. No acute mass was noted in either patient and vital signs were normal. A urine “dipstick” analysis was normal in the 30-year-old. The 44-year-old patient had a “large, protuberant abdomen” whereas the 30-year-old was not considered obese. The 44-year-old patient was sent to a surgeon and computed tomography (CT) imaging of the abdomen and pelvis was obtained (with contrast). The initial treating practitioner of the 30-year-old patient ordered a CT scan of the abdomen and pelvis (with contrast). Different radiologists interpreted the CT scans from the different patients. The 30-year-old patient was found to have “epiploic appendagitis of the proximal sigmoid colon” on CT scan. The 44-year-old patient exhibited “mild inflammatory change at the anterior aspect of the cecum, most consistent with epiploic appendagitis” on CT. The surgeon also diagnosed abdominal wall strain that was “work-related.” Primary epiploic appendagitis is produced by torsion and inflammation of finger-like projections of adipose tissue and blood vessels that extend from the colon. Symptoms can easily be mistaken for acute appendicitis, diverticulitis, hernia, or cholecystitis. Acute epiploic appendagitis is associated with obesity, hernia, and unaccustomed exercise. Historically, before CT scan was able to identify this entity, patients would sometimes undergo exploratory surgery for suspected appendicitis or acute abdomen. Treated conservatively, epiploic appendagitis generally resolves within 14 days. In the two cases reported here, one case resolved in approximately 3 weeks, and the other in approximately 5 weeks. Primary torsion of the omentum has been described in a jackhammer worker and was considered related to vibration.1 Torsion and inflammation of the epiploic appendages, although perhaps rare, should be a consideration in patients reporting for evaluation of work-related abdominal pain (after considering other serious causes requiring urgent treatment). There is possibility of the association of epiploic appendagitis with heavy physical activities. Carmine J. Pellosie, DO, MPH Richard Goy, MD, MPH Lauren Jacobsen, CRNP HeathWorks, a Division of Lehigh Valley Hospital and Health Network Allentown, PA