Citation, DOI & article data
Epiploic appendagitis is a rare self-limiting ischemic/inflammatory process involving appendix epiploica of the colon and may either be primary or secondary to adjacent pathology. This article pertains to primary (spontaneous) epiploic appendagitis. The term along with omental infarction is grouped under the broader umbrella term intraperitoneal focal fat infarction 9.
This condition usually affects patients in their 2nd to 5th decades with a predilection for women and obese individuals, presumably due to larger appendages 6. Its frequency is approximately 1.3% of cases with abdominal pain and its incidence is around 8.8 cases in every 1,000,000 yearly 10.
Patients typically 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 may be more localized than with other causes of acute abdominal pain.
Epiploic appendagitis merely denotes inflammation of one or more appendices 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 appendage epiploica, or spontaneous thrombosis of the venous outflow, resulting in ischemia and necrosis 3.
Ultrasound evaluation of the patient's area of maximal tenderness may reveal a rounded, non-compressible, 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.
The CT appearance is usually characteristic:
- a fat-density ovoid structure adjacent to the colon, usually 1.5-3.5 cm in diameter 2
- thin high-density rim, known as the hyperattenuating ring sign (1-3 mm thick) 5,6
- surrounding inflammatory fat stranding, and thickening of the adjacent peritoneum
- a central hyperdense dot (representing the thrombosed vascular pedicle) 6
- adjacent colonic wall thickening is not usually associated, but if present is usually minimal and the amount of fat inflammation is out of proportion to colonic wall thickening
- the inflamed appendage is classically located on the anterior aspect of the sigmoid or descending colon, but it may be located anywhere along the circumference of the colon, as seen in the atypical Case 22
Chronically, an infarcted epiploic appendage may calcify and may detach to form an intraperitoneal loose body (peritoneal 'mice').
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.
Although uncommonly used in a setting of acute abdominal pain, 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; hyperintense 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 responds well to NSAIDs.
History and etymology
Epiploic appendagitis was employed for the first time by Lynn et al. in 1956. The first CT description occurred in 1986 by Danielson et al 2.
Imaging differential considerations include:
- 1. Singh AK, Gervais DA, Hahn PF et-al. CT appearance of acute appendagitis. AJR Am J Roentgenol. 2004;183 (5): 1303-7. AJR Am J Roentgenol (full text) - Pubmed citation
- 2. Singh AK, Gervais DA, Hahn PF et-al. Acute epiploic appendagitis and its mimics. Radiographics. 25 (6): 1521-34. doi:10.1148/rg.256055030 - Pubmed citation
- 3. Boardman J, Kaplan KJ, Hollcraft C et-al. Radiologic-pathologic conference of Keller Army Community Hospital at West Point, the United States Military Academy: torsion of the epiploic appendage. AJR Am J Roentgenol. 2003;180 (3): 748. AJR Am J Roentgenol (full text) - Pubmed citation
- 4. Thomas JH, Rosato FE, Patterson LT. Epiploic appendagitis. Surg Gynecol Obstet. 1974;138 (1): 23-5. Pubmed citation
- 5. Rioux M, Langis P. Primary epiploic appendagitis: clinical, US, and CT findings in 14 cases. Radiology. 1994;191 (2): 523-6. Radiology (abstract) - Pubmed citation
- 6. Almeida AT, Melão L, Viamonte B et-al. Epiploic appendagitis: an entity frequently unknown to clinicians--diagnostic imaging, pitfalls, and look-alikes. AJR Am J Roentgenol. 2009;193 (5): 1243-51. doi:10.2214/AJR.08.2071 - Pubmed citation
- 7. Rao PM, Novelline RA. Case 6: primary epiploic appendagitis. Radiology. 1999;210 (1): 145-8. Radiology (full text) - Pubmed citation
- 8. Purysko AS, Remer EM, Filho HM et-al. Beyond appendicitis: common and uncommon gastrointestinal causes of right lower quadrant abdominal pain at multidetector CT. Radiographics. 2011;31 (4): 927-47. doi:10.1148/rg.314105065 - Pubmed citation
- 9. Coulier B. Contribution of US and CT for diagnosis of intraperitoneal focal fat infarction (IFFI): a pictorial review. JBR-BTR. 2010;93 (4): 171-85. Pubmed citation
- 10. de Brito P, Gomez MA, Besson M, Scotto B, Huten N, Alison D. Fréquence et épidémiologie descriptive de l'appendicite épiploïque primitive par l'exploration tomodensitométrique des douleurs abdominales de l'adulte [Frequency and epidemiology of primary epiploic appendagitis on CT in adults with abdominal pain]. J Radiol. 2008 Feb;89(2):235-43. French. PMID: 18354354. doi:10.1016/s0221-0363(08)70399-8