Torsion of the epiploic appendix: An unusual cause of acute abdomen

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.

Gangrenous epiploic appendagitis of sigmoid: a rare cause of acute right iliac fossa pain

A 42-year-old lady presented to emergency department with a 3 days history of right-sided abdominal pain. She was afebrile, haemodynamically unstable and the initial diagnosis was acute abdomen with unknown pathology. The CT abdomen/pelvis done, which showed well-defined fatty texture at right lower quadrant suggestive of an epiploic appendagitis and left adnexal cyst. The patient failed to improve on conservative management, diagnostic laparosocopy showed gangrenous sigmoid epiploic appendigitis adherent to the right lower quadrant. Excision of the gangrenous appendigitis done along with deroofing of left ovarian cyst. Postoperatively the patient significantly improved and discharged home. This case is an extremely rare case of right lower quadrant pain. It demonstrates the importance diagnostic laparoscopy in all patients failed to improve on conservative management with presumed appendigitis.

Torsion of an epiploic appendix pretending as acute appendicitis

Torsion of an epiploic appendix is a rare surgical entity. Its unusual symptomatology, wide variation in physical findings and the absence of helpful laboratory and radiological studies makes it very difficult to diagnose pre-operatively. This is a report of this rare entity found in a patient upon diagnostic laparoscopy performed for suspected acute appendicitis.

Intestinal obstruction secondary to torsion of an appendix epiploica: a case report

Introduction

Appendices epiploicae are affected by spontaneous torsion, calcification, primary or secondary inflammation, enlargement by lipomas or metastases and incarceration in hernias.

Case presentation

A 20-year-old Asian man was admitted with non-specific abdominal pain, which later evolved to intestinal obstruction. Operative findings showed the small bowel obstruction was due to an omental band adhered to a nodule. Histopathology of the nodule revealed an infarcted appendix epiploica.

Conclusion

Heightened suspicion and increased awareness of this entity would have led to an earlier diagnosis. Acute torsion of an appendage usually manifests as localised abdominal pain in one of the lower quadrants. Untreated, peritonitis or intestinal obstruction may result. Use of diagnostic laparoscopy in non-resolving abdominal pain would help to resolve the issue at an earlier stage and prevent additional morbidity.