Epiploic Appendagitis

What is Epiploic appendagitis?

Epiploic appendagitis can be defined as the inflammatory or ischemic process that occurs at the level of the epiploic appendices. There are certain characteristics that can be used in order to describe this inflammatory process – first of all, the condition is benign and self-limiting. It is non-surgical, which means that it cannot be solved through a surgical intervention. It is also an uncommon condition, which means that there are not many people diagnosed with it (rare cause of acute abdomen).In the past, it was also known as appendicitis epiploica – however, this term is rarely used nowadays, so as not to be confused with acute appendicitis. The epiploic appendices are actually small sacs that are filled with fat, which appear on the surface of the colon and rectum. They can be compared to finger-like projections, being present on both the upper and lower section of the colon.This condition can appear on its own or due to adjacent pathology. The patients who are between the 2nd and 5th decade of life are more often affected. Women and obese patients present the highest risks for developing this condition, due to the fact that their appendages are larger in size. One or more appendages can be inflamed – however, it is important to note that there are between 50 and 100 distributed throughout the colon and rectum. The most common area in which these are present is the rectosigmoid junction (57%), followed by the ileocecal region (26%), ascending colon (9%), transverse colon (6%) and descending colon (2%).

Causes

In the majority of the cases, the inflammatory process that occurs at the level of the epiploic appendices is due to a torsion of an appendage that is both large and pedunculated. In other patients, the venous thrombosis is responsible for the acute inflammation of the epiploic appendices (the thrombosis occurs at the level of the epiploic appendage central draining vein). When the spontaneous thrombosis of the venous overflow occurs, the patient will suffer from both ischemia and necrosis.

Symptoms

These are the most common symptoms caused by epiploic appendagitis:

• Pain
• Caused by the inflammatory process
• Characterized as sharp or stabbing
• Can be present in different regions of the abdomen (left, right, central), depending on the location of inflammation at the level of the colon/rectum
• Pain becomes aggravated during or after defecation or urination (the straining or emptying of the bowels or the bladder create a traction effect on the inflamed epiploic appendices, hence the aggravation of the pain)
• Nausea and vomiting
• Guarding can also be present as a symptom
• Focal peritoneal irritation

It is important to understand that the symptoms of epiploic appendagitis can very well resemble the ones of acute appendicitis, not to mention diverticulitis or cholecystitis. In general, if the epiploic appendagitis occurs on the right-side of the abdomen, it can mimic the symptoms of appendicitis and right-sided diverticulitis. However, if the condition occurs on the left-side of the abdomen, it will mimic the symptoms of sigmoid diverticulitis.

Diagnosis

Even though laboratory studies can be performed, they will not provide any information regarding this diagnosis. This condition is often diagnosed through imaging studies, such as CT scans. In the majority of the situations, the condition is diagnosed with mistake, the investigation being performed in order to exclude more severe health problems.These are the most common methods used for the diagnosis of epiploic appendagitis:

• Ultrasound
• A mass can be identified in the area of maximum tenderness
• The diameter is between 2 and 4 cm
• CT scan
• The inflamed epiploic appendages appear as ovoid structures, characterized by fat-density and adjacent to the colon
• The diameter of the appendages vary between 1.5 and 3.5 cm
• The appendages are surrounded by an area of inflammation
• A central hyperdense dot is also present (due to the thrombosed vascular pedicle)
• The involvement of the vermiform appendix can be noticed in rare cases
• MRI
• Not frequently performed
• May reveal the inflamed epiploic appendices

The imaging differential diagnosis can be made with following conditions: acute appendicitis (if the inflamed epiploic appendices is located on the right side), diverticulitis, mesenteric panniculitis, omental neoplasms, omental infarction.The correct diagnosis is essential, as there have been situations of inaccurate diagnoses, in which the patient was unnecessarily hospitalized, being treated with antibiotics or worse operated on.

Treatment

In general, this is a self-limiting disease and the treatment is often concentrated on the management of the symptoms. For the majority of the cases, the condition resolves itself on 5-7 days, without any surgical intervention being necessary. These are the recommended methods of treatment for epiploic appendagitis:

• Anti-inflammatory (NSAIDs) or pain medication Recommended as symptomatic treatment (pain, discomfort)
• Laparoscopic surgery
• Only recommended in patients who suffer from constant recurrences
• The inflamed appendage is excised through the laparoscopic surgical intervention, thus eliminating the risk of this condition recurring.