Epiploic Appendagitis: A Rare Cause of Acute Abdominal Pain

Abstract

Epiploic appendagitis is a self limiting condition presenting as acute abdomen and is often misdiagnosed without CT abdomen. A 34-year-old Caucasian male presented to our emergency room with progressive left sided abdominal pain for 3 days. Pain was constant sharp 7/10, in the left lower abdomen with no radiation. Lying on his left side helped alleviate the pain, with no exacerbating factors. He denied any fever, chills, diarrhea, constipation, urinary symptoms, nausea, vomiting or blood in stools. He had no history of recent trauma or travel. He didn't have any significant past medical history except for laparoscopic appendectomy for uncomplicated appendicitis 10 years ago. On physical exam, blood Pressure 116/74 mmHg, Pulse 112/minute, Temperature 98.7°F (37.1 °C) (Oral), Respiratory rate 16/minute, Oxygen saturation 97% on room air. He had localized tenderness in left lower quadrant with no guarding or rigidity. Bowel sounds were normal. Rest of the physical exam was unremarkable. An emergent Computerized Tomography scan of the abdomen and pelvis with contrast showed a 2 cm, fat density, oval shaped lesion with peripheral enhancement (consistent with hyperemia) and perilesional fat stranding and edema, adjacent to the descending colon. These findings were consistent with Epiploic Appendagitis. Patient was reassured and was treated conservatively. The diet was advanced to general diet the following day. He had significant improvement in the symptoms after receiving the pain medication and was observed in hospital. He had no further complications and expressed complete resolution of the symptoms and was discharged to home the following day. At 1 month follow up he did not have any further abdominal symptoms or complications. Epiploic appendagitis is an ischemic infarction of an epiploic appendage caused by torsion or spontaneous thrombosis of the central draining vein. Patients are usually young and present with localized abdominal pain and tenderness on exam. It is often misdiagnosed as appendicitis, bowel infarction or diverticulitis.CT scan is the diagnostic test of choice and shows characteristic findings of paracolonic well-defined fat density lesion with periappendageal fat stranding and thickened peritoneal ring, as in our patient. Management is conservative with anti-inflammatory medications or short course of opiates. The condition is self-resolving and awareness can avoid unnecessary use of antibiotics and surgical interventions.Figure: CT abdomen showing Oval paracolonic lesion, fat density, peripheral enhancement and surrounding fat stranding.