Epiploic appendagitis: is there need for surgery to confirm diagnosis in spite of clinical and radiological findings?

Prevalence of SIRS with primary epiploic appendagitis

PURPOSE

Primary epiploic appendagitis (PEA) is not an uncommon cause of abdominal pain. The systemic inflammatory response syndrome (SIRS) criteria have high sensitivity for early detection of inflammation and infection. To date, there is limited data about the association between SIRS and PEA. The aims of this retrospective study were to evaluate the prevalence of SIRS response and its clinical relevance in patients diagnosed with PEA within a large tertiary hospital network.

METHODS

A retrospective study was performed on all consecutive adult patients who presented to four major emergency departments with CT-confirmed PEA from 01 January 2022 to 27 March 2023. The fulfilment of SIRS criteria, hospital admission rate and treatments provided were analysed for these patients.

RESULTS

Seventy-three patients had CT-confirmed PEA. Seventeen patients (23.2%) with PEA were SIRS positive. The hospital admission rate in the SIRS group trended higher than the non-SIRS group (odds ratio of 2.51, 95% CI (0.75, 8.39)). The odds of having an associated radiological comorbidity unrelated to PEA were 18.7 times higher in the SIRS positive group. Fifty-seven (78%) patients were discharged home, and 16 (22%) patients were admitted into hospital. Nearly all patients were treated conservatively (98.6%).

CONCLUSION

PEA patients with SIRS response trend towards a higher hospital admission rate and are significantly more likely to have other radiological comorbidities than non-SIRS patients. It is important to look for other pathological conditions in a SIRS positive patient with a CT-diagnosis of PEA.

Primary Epiploic Appendagitis Mimicking Acute Appendicitis: A Case Report and Narrative Review of the Literature

Primary epiploic appendagitis is uncommon and is estimated to induce 1.1-1.3% of all abdominal pain. We report a 42-year-old male who appeared in the morning in the emergency department with abdominal pain localized in the right lower abdomen and associated with anorexia and nausea. Clinical examination, laboratory tests, and abdominal ultrasound revealed deep tenderness at Mc Burney point and a mild elevation of CRP (0.7 mg/dL). In the evening, the symptoms were exacerbated, and a diagnostic laparoscopy was performed. Intra-operatively, the appendix was normal and a twisted, necrotic epiploic appendage originating from the antimesenteric border of the mid ascending colon was found. Laparoscopic resection of the necrotic epiploic appendage and prophylactic appendectomy was carried out. Histology indicated the diagnosis of the necrotic epiploic appendage. Postoperatively, the patient recovered without complications. Although the preoperative diagnosis of primary epiploic appendagitis has improved due to abdominal ultrasound and mainly CT, there are still cases which are diagnosed during laparoscopy. The treatment of choice is conservative management, while the use of antibiotics remains controversial. The relapse and complication rates are rare. Surgical excision, particularly laparoscopic, should be considered in cases of uncertain diagnosis, persistent symptoms, or recurrence.

Epiploic Appendagitis: A Riddle for Right Lower Quadrant Pain!

Epiploic appendagitis (EA) is inflammation of epiploic appendages, which are pedunculated fatty structures, extend from the cecum to the rectosigmoid junction, and are covered by the peritoneum. Torsion, infarction, and inflammation of it present with acute lower abdominal pain and localized tenderness in a well-looking patient. It poses as diagnostic conundrum due to its rarity and not picked by conventional radiography. A 50-year-old male presented with pain in RLQ for past 1 day, which kept on increasing without any other symptoms. His abdomen was soft with tenderness localized to the right lower quadrant (RLQ), classically at McBurney's point along with mild peritonism. Rest laboratory test, chest, and abdominal X-ray were normal except slight leukocytosis. Ultrasound was inconclusive. A working clinical diagnosis of appendicitis was made. Patient did not consent for surgery and was started on antibiotics with pain killers. With no significant improvement, he underwent CT scan which revealed focal area of soft-tissue attenuation along the lateral wall of ascending colon with fat stranding. He was diagnosed as EA and improved on conservative treatment. EA of RLQ of abdomen mimics acute appendicitis and can be considered as an uncommon differential diagnosis in presence of radiological findings of normal-appearing appendix. CT is the investigation of choice, and treatment is essentially conservative. Further, if appendix is found normal at exploration, surrounding epiploic appendages of the cecum and ascending colon should also be evaluated carefully for inflammation/hematoma/gangrene, besides looking for Meckel's diverticulum.

Clinical Awareness and Acceptance of Sonographically Diagnosed Epiploic Appendagitis (EA): A Retrospective Analysis of EA in a Single Tertiary Academic Referral Center

Purpose To describe the clinical awareness and acceptance of ultrasound-diagnosed acute epiploic appendagitis (EA) and their importance to avoid unnecessary therapeutic and imaging measures. Patients and Methods The data were obtained of n=54 patients with acute, localized, peritonitic pain and EA diagnosed by B-mode ultrasound and contrast-enhanced ultrasound examination from November 2003 to September 2020. All examinations were performed by a German Society for Ultrasound in Medicine (DEGUM) Level III qualified examiner. Based on documentation by the treating physicians, the clinical awareness and acceptance of EA diagnosis was determined in all patients and compared between subgroups diagnosed before 2013 and from 2013 onwards. In 2013, a local educational training program regarding the diagnosis of and therapy for EA was initiated for physicians. Results In all patients, EA was sonographically diagnosed by a DEGUM level III qualified examiner. At enrollment, EA was mentioned as a suspected clinical diagnosis in n=1/54 (1.9%) patient. Furthermore, in n=39/54 (72.2%) cases, the EA was documented and accepted by the treating physicians at the time of patient discharge as the final clinical diagnosis. The clinical acceptance was significantly higher from 2013 onwards compared with before 2013 (p<0.05). Moreover, in n=26/54 (48.1%) patients, unnecessary therapeutic measures were initiated, with no significant difference between pre-2013 and post-2013 numbers (p>0.05). Conclusion In our retrospective study, we showed that awareness and acceptance of the disease EA are low. Low diagnostic acceptance of EA by the clinician leads to unnecessary therapeutic and imaging measures and is a general problem related to rare diseases in the healthcare system.

Acute abdomen in adult revealing unusual complicated epiploic appendagitis: A case report

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Think about the epiploic appendagitis more frequently when dealing with an obese patient with predispositions.

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Understand the importance of imagery that avoids unnecessary surgery in case of uncomplicated epiploic appendagitis and make it possible to do a radiological drainage.

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Always make the necessary differential diagnoses before evoking appendagitis.

Introduction

Epiploic appendagitis is a torsion of fatty appendages of ligamentum trees (1), it’s a rare cause of abdominal pain that usually manifests by right or left iliac fossa pain, reminding of appendicitis, diverticulitis or ischemia of the omentum.

Case presentation

We report the case of a 56 years old male patient admitted for an epigastric pain and a right-upper quadrant abdominal pain, for whom he underwent an abdominal ultrasound and a CT-scan who shown an abscessed mass under colic transverse to the unusual seat.

Discussion

CT scan is still the key modality for diagnosis, avoiding unnecessary surgery. Complications of primary epiploic appendagitis have rarely been described in the literature (Hwang et al., 2013; Hasbahceci et al., 2012). Another more rare complication is appendagitis with associated abscess, in this condition, we must also think about complicated diverticulitis.

The treatment of uncomplicated forms is generally conservative, however, some authors have suggested a surgical method (Saad et al., 2014).

For therapeutic management of its complication, there has been much interest in the use of minimally invasive techniques such as percutaneous drainage to minimize the morbidity and mortality that is associated with surgery (Evidence National Guideline Centre (UK), 2019).

Conclusion

The diagnosis of epiploic appendagitis is still uncommon, CT scan can eliminate other diagnosis of acute abdominal pain such as diverticulitis and appendicitis. It also allows the diagnosis of the rare complicated forms such as abscesses associated with epiploic appendagitis.

The treatment of typical forms is usually conservative, while the complicated form requires surgery because of the potential associated pathology.

Peritoneal loose bodies and the differentiation of fatty abdominal and pelvic lesions

Peritoneal loose bodies (PLBs) have been sparingly documented within the surgical and radiologic literature, with 38 cases reported to date. A 67-year-old male presented to urology for the management of an asymmetric prostatic nodule. Imaging incidentally identified a well-circumscribed mass of low T2 signal intensity with a small fatty core in the left lower quadrant close to the sigmoid colon; malignancy was in the differential. The mass grew slightly over the next year. A diagnostic laparoscopy retrieved a free floating 4 × 4 cm benign mass from the pelvis, identified as necrotic fat with areas of dystrophic calcifications. PLBs are often a diagnostic dilemma without surgical intervention. Here we present a diagnostic algorithm based on a comprehensive literature review and our case to help better identify unknown abdominal and pelvic fatty masses and to avoid surgery strictly for diagnosis, especially for patients that are not ideal surgical candidates. Using this algorithm, the mass in the patient presented here could have been accurately characterized without invasive diagnostic measures.

Acute epiploic appendagitis: ultrasound and computed tomography findings of a rare case of acute abdominal pain and the role of other imaging techniques

PURPOSE

Acute epiploic appendagitis (EA) is a relatively rare, benign and local inflammatory disease involving the epiploic appendices. Unlike its mimics, EA is generally a self-limiting inflammatory disease and can be treated conservatively.

CASE PRESENTATION

A 33-year-old Caucasian man presented to our emergency department with a sever and sharp left iliac fossa pain. He underwent abdominal X-ray, ultrasound (US) and computed tomography (CT) evaluations.

CONCLUSION

We illustrate US and CT findings to increase the radiologists' awareness of this condition and to avoid diagnostic delay and unnecessary use of antibiotics, hospitalization and surgery.

Epiploic appendagitis: pathogenesis, clinical findings and imaging clues of a misdiagnosed mimicker

Primary epiploic appendagitis (PEA) is a rare and frequently underdiagnosed cause of acute abdominal pain. PEA most commonly affects obese, male patients in the 4th and 5th decade of life. Clinical presentation includes acute, localized, non-migrating pain without fever, nausea, vomiting or diarrhea and the laboratory workup is usually within normal limits. PEA is commonly mistaken as other more severe causes of acute abdominal pain, such as diverticulitis, acute appendicitis or cholecystitis and thus patients undergo unnecessary diagnostic and therapeutic procedures. The emergence of computerized tomography (CT) as the gold standard imaging test in diagnostic dilemmas of acute abdominal pain has resulted in increased recognition and diagnosis of PEA. Upon confirmation, PEA is considered a self-limiting disease and is managed conservatively with analgesics, occasionally combined with nonsteroidal anti-inflammatory drugs (NSAIDS). Persistence of symptoms or recurrence mandate the consideration of surgical management with laparoscopic appendage excision as the definitive treatment. We review the current literature of PEA, with a focus on clinical and imaging findings, in order to raise awareness about this frequently misdiagnosed entity.

Primary epiploic appendagitis: compared with diverticulitis and focused on obesity and recurrence

Background/Aims

There is limited data to compare the clinical characteristics and recurrence rates between left-sided primary epiploic appendagitis (PEA) versus left-sided acute colonic diverticulitis (ACD), and right-sided PEA versus right-sided ACD, respectively.

Methods

We retrospectively reviewed the medical records and radiologic images of the patients who presented with left-sided or right-sided acute abdominal pain and had computer tomography performed at the time of presentation showing radiological signs of PEA or ACD between January 2004 and December 2014. We compared the clinical characteristics of left PEA versus left ACD and right PEA versus right ACD, respectively.

Results

Fifty-six patients (left:right = 27:29) and 308 patients (left:right = 24:284) were diagnosed with symptomatic PEA and ACD, respectively. Left-sided PEA were statistically significantly younger (50.2 ± 15.4 years vs. 62.1 ± 15.8 years, P= 0.009), more obese (body mass index [BMI]: 26.3 ± 2.9 kg/m² vs. 22.3 ± 3.1 kg/m² , P< 0.001), and had more tendencies with normal or mildly elevated high-sensitivity C-reactive protein (hsCRP) (1.2 ± 1.3 mg/dL vs. 8.4 ± 7.9 mg/dL, P< 0.001) than patients with left-sided ACD. The discriminative function of age, BMI and CRP between left-sided PEA versus left-sided ACD was 0.71 (cutoff: age ≤ 59 years, sensitivity of 66.7%, specificity of 77.8%), 0.84 (cutoff: BMI > 24.5 kg/m² , sensitivity of 80.0%, specificity of 80.0%) and 0.80 (cutoff: CRP < 1.8 mg/dL, sensitivity of 72.2%, specificity of 85.7%).

Conclusions

If patients with left lower quadrant abdominal pain are less than 60 years, obese (BMI > 24.5 kg/m² ) with or without normal to mild elevated CRP levels (CRP < 1.8 mg/dL), it might be necessary for clinicians to suspect the diagnosis of PEA rather than ACD.

Acute Epiploic Appendagitis: A Nonsurgical Abdominal Pain

Epiploic appendagitis is a relatively rare disease characterized by an inflammation of fat-filled serosal outpouchings of the large intestine, called epiploic appendices. Diagnosis of epiploic appendagitis is made challenging by the lack of pathognomonic clinical features and should therefore be considered as a potential diagnosis by exclusion first of all with appendicitis or diverticulitis which are the most important causes of lower abdominal pain. Currently, with the increasing use of ultrasound and computed tomography in the evaluation of acute abdominal pain, epiploic appendagitis can be diagnosed by characteristic diagnostic imaging features. We present a case of epiploic appendagitis with objective of increasing knowledge of this disease and its diagnostic imaging findings, in order to reduce harmful and unnecessary surgical interventions.

Impact of Radiology Report Wording on Care of Patients With Acute Epiploic Appendagitis

OBJECTIVE. The purpose of this study was to evaluate the association between the diagnostic certainty expressed by the wording of CT report impressions and subsequent use of standard treatment with analgesics versus nonstandard antibiotic administration in patients with acute epiploic appendagitis (EA). MATERIALS AND METHODS. Demographic, clinical, and radiologic data from a 10-year cohort of patients with acute EA were retrospectively analyzed and correlated with standard treatment with analgesics versus nonstandard treatment with antibiotics. A level of certainty was assigned to the CT report language based on the wording of the impression statements by two radiologists; their interreader agreement was assessed with kappa statistics. Bivariate analyses were performed to correlate all variables with antibiotic administration and to assess for collinearity. Multivariate logistic regression was performed to identify independent predictors of antibiotic use in patients with acute EA. RESULTS. Of 124 patients with CT-diagnosed acute EA, 22% (27/124) received antibiotic treatment. After the CT report impressions were evaluated, 27% (34/124) were categorized as low certainty and 73% (90/124) as high certainty (κ = 0.958, p < 0.001). Multivariate regression was significant (p < 0.001, Nagelkerke R² = 0.249) and found CT report impressions' level of certainty (odds ratio [OR] = 6.1, p < 0.001) and evaluation in an outpatient clinic rather than an emergency department (ED) (OR = 4.4, p = 0.003) to be independent predictors of antibiotic administration for patients with acute EA. Outpatient presentation was also correlated with age, abdominal pain duration, and left-colonic involvement in the bivariate analysis (all p ≤ 0.01). CONCLUSION. The diagnostic certainty conveyed by the wording of CT report impressions correlated with antibiotic treatment decisions for patients with acute EA. Patients whose report impressions expressed low rather than high certainty were six times more likely to receive antibiotic therapy; patients evaluated at outpatient clinics rather than EDs were four times more likely.

CT imaging findings of epiploic appendagitis: an unusual cause of abdominal pain

Epiploic appendagitis is a rare cause of acute abdominal pain, determined by a benign self-limiting inflammation of the epiploic appendages. It may manifest with heterogeneous clinical presentations, mimicking other more severe entities responsible of acute abdominal pain, such as acute diverticulitis or appendicitis. Given its importance as clinical mimicker, imaging plays a crucial role to avoid inaccurate diagnosis that may lead to unnecessary hospitalization, antibiotic therapy, and surgery. CT represents the gold standard technique for the evaluation of patients with indeterminate acute abdominal pain. Imaging findings include the presence of an oval lesion with fat-attenuation surrounded by a thin hyperdense rim on CT (“hyperattenuating ring sign”) abutting anteriorly the large bowel, usually associated with inflammation of the adjacent mesentery. A central high-attenuation focus within the fatty lesion (“central dot sign”) can sometimes be observed and is indicative of a central thrombosed vein within the inflamed epiploic appendage. Rarely, epiploic appendagitis may be located within a hernia sac or attached to the vermiform appendix. Chronically infarcted epiploic appendage may detach, appearing as an intraperitoneal loose calcified body in the abdominal cavity. In this review, we aim to provide an overview of the clinical presentation and key imaging features that may help the radiologist to make an accurate diagnosis and guide the clinical management of those patients.

Diagnostic point-of-care ultrasound (POCUS) for gastrointestinal pathology: state of the art from basics to advanced

The use of point-of-care ultrasound (POCUS) by non-radiologists has dramatically increased. POCUS is completely different from the routine radiological studies. POCUS is a Physiological, On spot, extension of the Clinical examination, that is Unique, and Safe. This review aims to lay the basic principles of using POCUS in diagnosing intestinal pathologies so as to encourage acute care physicians to learn and master this important tool. It will be a useful primer for clinicians who want to introduce POCUS into their clinical practice. It will cover the basic physics, technical aspects, and simple applications including detection of free fluid, free intraperitoneal air, and bowel obstruction followed by specific POCUS findings of the most common intestinal pathologies encountered by acute care physicians including acute appendicitis, epiploic appendagitis, acute diverticulitis, pseudomembranous colitis, intestinal tuberculosis, Crohn’s disease, and colonic tumours. Deep understanding of the basic physics of ultrasound and its artefacts is the first step in mastering POCUS. This helps reaching an accurate POCUS diagnosis and avoiding its pitfalls. With increased skills, detailed and accurate POCUS findings of specific intestinal pathologies can be achieved and properly correlated with the clinical picture. We have personally experienced and enjoyed this approach to a stage that an ultrasound machine is always accompanying us in our clinical on calls and rounds.

Torsion of epiploic appendix presenting as acute pancreatitis

Epiploic appendagitis is a little-diagnosed condition capable of mimicking various pathologies. Here, we present a case presenting as acute pancreatitis.

Recurrent epiploic appendagitis and peritoneal dialysis: A case report and literature review

Epiploic appendagitis (EA) is rare cause of acute or subacute abdominal pain in patients on peritoneal dialysis (PD), where the diagnosis can be challenging as the clinical features, laboratory markers and imaging characteristics have not been described previously in this group of patients. Here, we present the management of a case of EA in a patient on PD and review published literature pertinent to the subject. The importance of establishing the diagnosis early by laparoscopy is emphasised.