Epiploic Appendagitis: Underappreciated and Easily Misdiagnosed and Often Masquerading as an Acute Abdomen

Abstract

Purpose: A 44-year-old male with past medical history of gastroesophageal reflux disease and peptic ulcer disease presented with four days of severe left lower quadrant abdominal pain, nausea and constipation. At the onset of symptoms, the patient was seen at a local ER where he was diagnosed and treated for presumed diverticulitis and discharged home on Metronidazole and Ciprofloxacin. However, the pain subsequently worsened and he was referred to our institution for evaluation and treatment. ER vital signs showed temperature 97.4°F, blood pressure 110/71 mmHg, heart rate 67 beats/min, and respiratory rate of 18 breaths/min. Patient described the pain as sharp, 10/10 in intensity, localized to left lower quadrant, non-radiating, associated with nausea, but no vomiting. On physical examination, his abdomen was tense, non-distended, tender in LLQ with positive guarding but no rebound and normal bowel sounds were present. The rest of physical examination was unremarkable. Laboratory analysis showed a white blood cell count of 6.7 K/Ul with 67% neutrophil count. The remainder of the laboratory tests were within normal limits. He was started on morphine for pain and broad spectrum antibiotics for presumed diverticulitis with possible abscess formation. Computed tomography of abdomen and pelvis was performed showing an oval shaped fat density in the left lower quadrant anterior to the sigmoid colon characteristic of epiploic appendagitis. Patient improved with conservative treatment including NSAIDS and was discharged home after resolution of symptoms. Epiploic appendagitis is a benign condition of the epiploic appendages, which can affect anyone including young and healthy individuals. It often mimics other serious surgical conditions such as acute diverticulitis, appendicitis and even cholecystitis. Complete resolution of symptoms typically occurs within two weeks with conservative treatment, primarily anti-inflammatory agents. The infrequency of epiploic appendagitis makes this condition an unusual and difficult diagnosis for many physicians. Therefore, improved awareness and recognition of epiploic appendagitis can lead to fewer misdiagnoses, thereby decreasing redundant medical procedures as well as unnecessary surgical interventions.Figure: No Caption available.