Epiploic appendagitis
Updates to Article Attributes
Epiploic appendagitis is a rare self limiting inflammatory/ischaemic process involving an appendix epiploica of the colon, and may either be primary or secondary to adjacent pathology. This article pertains to primary (spontaneous) epiploic appendagitis.
Epidemiology
This condition usually affects patients in their 2nd to 5th decades with a predilection for women and obese individuals, presumably due to larger appendicesappendages 6.
Clinical presentation
Clinically patients present with abdominal pain and guarding. It is essentially indistinguishable from diverticulitis and acute appendicitis (depending on location) and although an uncommon condition, it accounts for up to 7% of cases of suspected diverticulitis 1. Since there is focal peritoneal irritation, pain maybe more localized than in the other causes of acute abdominal pain.
Pathology
Epiploic appendagitis merely denotes inflammation of the one or more appendicesappendages epiploicae, which number 50-100 and are distributed along the large bowel with variable frequency 3-4,6:
- rectosigmoid junction: 57%
- ileocecal region: 26%
- ascending colon: 9%
- transverse colon: 6%
- descending colon: 2%
The pathogenesis is thought to be due to torsion of a large and pedunculated appendixappendage epiploicae, or spontaneous thrombosis of the venous outflow, resulting in ischaemia and necrosis 3.
Radiographic features
Ultrasound
Ultrasound guided by the patients area of maximal tenderness may reveal a rounded, noncompressible, hyperechoic mass, without internal vascularity, and surrounded by a subtle hypoechoic line 5. They are typically 2-4 cm in maximal diameter.
They typically exert local mass effect but are not usually associated with bowel wall thickening or ascites 5.
CT
CT appearances are usually characteristic consisting of:
- a fat-density ovoid structure adjacent to colon, usually 1.5- 3.5cm in diameter 2
- thin high-density rim (1-3mm thick) 5-6
- surrounding inflammatory fat stranding, and thickening of the adjacent peritoneum
- central hyperdense dot (representing the thrombosed vascular pedicle) 6
Chronically, an infarcted appendixappendage epiploica may calcify, and may detach to form an intraperitoneal loose body.
It may rarely involve the vermiform appendix epiploic appendages as so called epiploic appendagitis of the vermiform appendix 8, mimicking appendicitis both clinically and potentially on CT.
MRI
Although not frequently performed for this indication MRI features are also characteristic 6:
- T1: often shows a rounded high signal mass with slightly reduced signal compared to normal fat, due to inflammatory stranding; hypointense 2-3 mm rim
- T2: often seen as a high signal mass which attenuates on fat suppressed sequences; hyper-intense 2-3 mm rim with surrounding high signal stranding; central low signal vein
- T1 C+ (Gd): shows vivid rim enhancement
Treatment and prognosis
Epiploic appendagitis is a self limiting disease, and thus correct identification on CT prevents unnecessary surgery 2. Although it sometimes mimics acute abdominal diseases for which surgery is required, treatment options for epiploic appendagitis often do not include surgery, It usually reponds well to NSAIDs.
Differential diagnosis
Imaging differential considerations include:
- acute appendicitis: if right sided
- diverticulitis
- mesenteric panniculitis
- omental neoplasms e.g. exophytic angiomyolipoma, atypical liposarcoma
- omental infarction
-<p><strong>Epiploic appendagitis</strong> is a rare self limiting inflammatory/ischaemic process involving an <a href="/articles/appendix-epiploica">appendix epiploica</a> of the <a href="/articles/colon">colon</a>, and may either be primary or secondary to adjacent pathology. This article pertains to <strong>primary (spontaneous) epiploic appendagitis</strong>. </p><h4>Epidemiology</h4><p>This condition usually affects patients in their 2<sup>nd</sup> to 5<sup>th </sup>decades with a predilection for women and obese individuals, presumably due to larger appendices <sup>6</sup>. </p><h4>Clinical presentation</h4><p>Clinically patients present with abdominal pain and guarding. It is essentially indistinguishable from <a href="/articles/diverticulitis">diverticulitis</a> and <a href="/articles/acute-appendicitis">acute appendicitis</a> (depending on location) and although an uncommon condition, it accounts for up to 7% of cases of suspected <a href="/articles/diverticulitis">diverticulitis</a> <sup>1</sup>. Since there is focal peritoneal irritation, pain maybe more localized than in the other causes of acute abdominal pain.</p><h4>Pathology</h4><p>Epiploic appendagitis merely denotes inflammation of the one or more appendices epiploicae, which number 50-100 and are distributed along the large bowel with variable frequency <sup>3-4,6</sup>:</p><ul>- +<p><strong>Epiploic appendagitis</strong> is a rare self limiting inflammatory/ischaemic process involving an <a href="/articles/appendix-epiploica">appendix epiploica</a> of the <a href="/articles/colon">colon</a>, and may either be primary or secondary to adjacent pathology. This article pertains to <strong>primary (spontaneous) epiploic appendagitis</strong>. </p><h4>Epidemiology</h4><p>This condition usually affects patients in their 2<sup>nd</sup> to 5<sup>th </sup>decades with a predilection for women and obese individuals, presumably due to larger appendages <sup>6</sup>. </p><h4>Clinical presentation</h4><p>Clinically patients present with abdominal pain and guarding. It is essentially indistinguishable from <a href="/articles/diverticulitis">diverticulitis</a> and <a href="/articles/acute-appendicitis">acute appendicitis</a> (depending on location) and although an uncommon condition, it accounts for up to 7% of cases of suspected <a href="/articles/diverticulitis">diverticulitis</a> <sup>1</sup>. Since there is focal peritoneal irritation, pain maybe more localized than in the other causes of acute abdominal pain.</p><h4>Pathology</h4><p>Epiploic appendagitis merely denotes inflammation of the one or more appendages epiploicae, which number 50-100 and are distributed along the large bowel with variable frequency <sup>3-4,6</sup>:</p><ul>
-</ul><p>The pathogenesis is thought to be due to torsion of a large and pedunculated appendix epiploicae, or spontaneous thrombosis of the venous outflow, resulting in ischaemia and necrosis <sup>3</sup>.</p><h4>Radiographic features</h4><h5>Ultrasound</h5><p>Ultrasound guided by the patients area of maximal tenderness may reveal a rounded, noncompressible, hyperechoic mass, without internal vascularity, and surrounded by a subtle hypoechoic line <sup>5</sup>. They are typically 2-4 cm in maximal diameter.</p><p>They typically exert local mass effect but are not usually associated with bowel wall thickening or ascites <sup>5</sup>.</p><h5>CT</h5><p>CT appearances are usually characteristic consisting of:</p><ul>- +</ul><p>The pathogenesis is thought to be due to torsion of a large and pedunculated appendage epiploicae, or spontaneous thrombosis of the venous outflow, resulting in ischaemia and necrosis <sup>3</sup>.</p><h4>Radiographic features</h4><h5>Ultrasound</h5><p>Ultrasound guided by the patients area of maximal tenderness may reveal a rounded, noncompressible, hyperechoic mass, without internal vascularity, and surrounded by a subtle hypoechoic line <sup>5</sup>. They are typically 2-4 cm in maximal diameter.</p><p>They typically exert local mass effect but are not usually associated with bowel wall thickening or ascites <sup>5</sup>.</p><h5>CT</h5><p>CT appearances are usually characteristic consisting of:</p><ul>
-</ul><p>Chronically, an infarcted appendix epiploica may calcify, and may detach to form an intraperitoneal loose body. </p><p>It may rarely involve the vermiform appendix epiploic appendages as so called <strong>epiploic appendagitis of the vermiform appendix</strong> <sup>8</sup>, mimicking <a href="/articles/tip-appendicitis">appendicitis</a> both clinically and potentially on CT.</p><h5>MRI</h5><p>Although not frequently performed for this indication MRI features are also characteristic <sup>6</sup>:</p><ul>- +</ul><p>Chronically, an infarcted appendage epiploica may calcify, and may detach to form an intraperitoneal loose body. </p><p>It may rarely involve the vermiform appendix epiploic appendages as so called <strong>epiploic appendagitis of the vermiform appendix</strong> <sup>8</sup>, mimicking <a href="/articles/tip-appendicitis">appendicitis</a> both clinically and potentially on CT.</p><h5>MRI</h5><p>Although not frequently performed for this indication MRI features are also characteristic <sup>6</sup>:</p><ul>
-</ul><h4>Treatment and prognosis</h4><p>Epiploic appendagitis is a self limiting disease, and thus correct identification on CT prevents unnecessary surgery <sup>2</sup>. Although it sometimes mimics acute abdominal diseases for which surgery is required, treatment options for epiploic appendagitis often do not include surgery, </p><h4>Differential diagnosis</h4><p>Imaging differential considerations include:</p><ul>- +</ul><h4>Treatment and prognosis</h4><p>Epiploic appendagitis is a self limiting disease, and thus correct identification on CT prevents unnecessary surgery <sup>2</sup>. Although it sometimes mimics acute abdominal diseases for which surgery is required, treatment options for epiploic appendagitis often do not include surgery, It usually reponds well to NSAIDs.</p><h4>Differential diagnosis</h4><p>Imaging differential considerations include:</p><ul>
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