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Cecal Epiploic Appendagitis: A Diagnostic and Therapeutic Dilemma

September 15, 2007

By Patel, Vijaykumar G Rao, Arundathi; Williams, Reginald; Srinivasan, Radha; Et al

Acute epiploic appendagitis (EA) is a rare and often misdiagnosed cause of acute abdominal pain. Though a benign and often self- limiting condition, EA’s ability to mimic other disease processes makes it an important consideration in patients presenting with acute abdominal symptoms. Careful evaluation of abdominal CT scan findings is crucial in the accurate diagnosis of epiploic appendagitis, thus avoiding unnecessary surgical intervention. We report a case of a 29-year-old male presenting with a two day history of generalized abdominal pain. Physical exam revealed a diffusely tender abdomen with hypoactive bowel sounds. The patient had a leukocytosis of 18,000 and abdominal CT scan revealed right lower quadrant inflammatory changes suggestive of acute appendicitis. Laparoscopic exploration revealed an inflamed gangrenous structure adjacent to the ileocecal junction. Pathologic evaluation revealed tissue consistent with epiploic appendagitis. Retrospective review of the CT scan revealed a normal appearing appendiceal structure superolateral to the area of inflammation. The patient recovered uneventfully with resolving leukocytosis. We present a case of cecal epiploic appendagitis mimicking acute appendicitis and review the current literature on radiographic findings, diagnosis, and treatment of this often misdiagnosed condition. General surgeons should be aware of this self-limiting condition and consider this in the differential diagnosis. PRIMARY EPIPLOIC APPENDAGITIS (PEA) usually presents as an acute clinical condition that often mimics a surgical emergency. PEA is an uncommon condition and is due to appendix epiploica torsion or spontaneous venous thrombosis of its’ draining vein.1 Patients present with nonspecific symptoms that can mimic appendicitis, diverticulitis, ovarian torsion, gallbladder disease, ectopie pregnancy, colon cancer, mesenteric adenitis, duodenal ulcer, and, on rare occasions, pulmonary embolus.2,3 Failure to diagnose PEA results in an unnecessary surgical intervention and incurred hospital costs. Therefore, it is imperative to appropriately diagnose this self- limiting condition to avoid surgery and prevent furthermore unwarranted hospitalization.

Case Report

A 29-year-old male presented to the emergency department with a two-day history of generalized abdominal pain and constipation. The patient was tachycardie and tachypneic with a temperature of 102[degrees] F. Physical exam revealed a 400 pound obese male in moderate distress with a diffusely tender abdomen and hypoactive bowel sounds. A leukocytosis of 18,000 and a urinalysis was negative for bacteria, blood, and nitrites. CT scan revealed a normal seeming cecum. However, right lower quadrant inflammation and a small amount of free fluid in the pelvis was reported by the attending radiologist, as suggestive of acute appendicitis (Fig. 1). Laparoscopic exploration revealed an inflamed gangrenous structure adjacent to the ileocecal junction, which seemed to be the appendix.

Pathologic evaluation revealed tissue consistent with epiploic appendagitis. Retrospective review of the CT scan revealed a normal seeming appendiceal structure superolateral to the area of inflammation (Fig. 1). Postoperatively, the patient remained afebrile with resolving leukocytosis and was discharged home after two days.

Discussion

First described by Versalius in 1543, epiploic appendages are adipose tags attached in two parallel rows adjacent to the anterior and posterior taenia coli along the entire length of the colon.2′ 4 These appendages develop in the 2nd trimester of fetal life and grow throughout adulthood and can reach lengths from 0.5 cm to 15 cm and 1 to 2 cm thick.2- 5 They are located primarily along the sigmoid colon (57%), and ileocecum (26%), followed by the ascending colon (9%), transverse colon (6%), and descending colon (2%).5 Epiploic appendices have a delicate blood supply consisting of a small end artery and a tortuous vein, which pass through narrow pedicles. The extreme mobility of these appendices predisposes to torsion, kinking, stretching, and surrounding inflammatory processes, resulting in venous thrombosis.6

FIG. 1. Abdominal CT scan images showing inflammatory changes medial to the cecum (c). Hypodense area in the ileocecal region is consistent with fatty epiploic appendagitis (ea).

Ly nn et al. first coined the phrase epiploic appendagitis in 1956, describing the inflammatory result of these torsed appendages.7 Primary epiploic appendagitis is a result of spontaneous torsion or lymphoid hyperplasia with subsequent inflammation. Secondary epiploic appendagitis is much more common and most often occurs secondarily in the inflammatory setting of appendicitis, diverticulitis, and cholecystitis.8

Epiploic appendagitis occurs in all ages with slightly higher predilection towards middle-aged males with a peak incidence at age 40 years.4,6 Appendagitis may be more common in obese people or those who have recently lost weight.9 Many patients will present with a recent history of strenuous stretching or exercising as the precipitating event.2

Patients usually present with a sudden onset of localized abdominal pain and tenderness lasting several days to almost a week in duration (100%).6 Pain can be quite severe, and stretching of the abdominal wall may furthermore elicit pain (100%).6 Rebound tenderness was also noted in 91 per cent of patients in one study.1 Fever and leukocytosis are common, along with gastrointestinal symptoms, in as many as 25 per cent of patients, as was seen in our case report. Some studies suggest absence of gastrointestinal symptoms and fever in true PEA.5 With this variable presentation; it is easy to see why accurate diagnosis of PEA based on clinical evaluation alone is often difficult.

In 1986, abdominal CT scan findings of PEA were first described. PEA has a pathognomonic appearance on abdominal CT scan, consisting of a one to four centimeter pedunculated, ovoid paracolic mass with hyper attenuation of the rim and surrounding fat stranding.10 Other documented findings include thickening of the bowel with or without compression of the bowel wall and a high central attenuation dot/ linear sign.3 The ultrasonographic appearance of PEA consists of a solid hyper echoic noncompressible ovoid mass with no color Doppler flow.11 Abdominal MRI findings in PEA are also pathognomonic. Tl- weighted images reveal high-signal paracolic lesions with a thin rim and a central low-signal dot. Lesions are best seen on postgadolinium Tl-weighted fat suppressed images.

Despite these imaging techniques, erroneous diagnoses are still common, as was seen in our case. Epiploic appendages surrounding the colon are clustered most prominently in the cecal and recto-sigmoid region, hence the mistaken diagnosis of diverticulitis and appendicitis are most common.4 Misdiagnosis usually leads to operative intervention and can present as a dilemma if a laparoscopie diagnosis is made. Vazquez-Frias et al. published recommendations in favor of excising infarcted appendages during laparoscopy.12

Radiological or clinical misdiagnosis can contribute substantially to unnecessary surgery, medical treatment, and hospital resources utilization.1 Patients with true PEA require analgesics alone. Spontaneous symptom resolution occurs within one to two weeks in most cases.6 Close follow-up is imperative because potential complications such as bowel obstruction, intussusception, and possible abscess formation can arise.2

Conclusion

Awareness of PEA is of crucial importance because clinical signs and symptoms are often nonspecific. Well-established abdominal CT scan and ultrasound findings in diagnosing this unusual entity have been well described. Therefore, with careful radiological evaluation, the diagnosis of PEA can be made with confidence, thus preventing unnecessary surgical intervention, antibiotic therapy, and prolonged hospitalization. General surgeons and radiologists should be aware of this rare, self -limiting condition and consider this in the differential diagnosis, particularly in obese male patients. With increasing utilization of CT scans in the diagnosis of appendicitis, this rare self-limiting entity may be recognized more frequently with increased awareness.

REFERENCES

1. Rao PM, Rhea JT, Wittenberg J, Warshaw AL. Misdiagnosis of primary epiploic appendagitis. Am J Surg 1998;176:81-5.

2. Legome EL, Sims C, Rao PM. Epiploic appendagitis: Adding to the differential of acute abdominal pain. J Emerg Med 1999;17:823- 6.

3. Keng SN, Tan GST, Chen KKW, et al. CT features of primary epiploic appendagitis. Eur J Radiol 2006;59:284- 8.

4. Sangha S, Soto JA, Becker JM, Farraye FA. Primary epiploic appendagitis: An underappreciated diagnosis. A case series and review of the literature. Dig Dis Sci 2004;49:347-50.

5. Killer N, Berelowitz D, Hadas-Halpern I. Primary epiploic appendagitis: Clinical and radiological manifestations. Isr Med Assoc J 2000;2:896-8.

6. Vriesman ACB, Otterloo AJCM, Puylaert JBCM. Epiploic appendagitis and omental infarction. Eur J Surg 2001;167:723-7.

7. Lynn TE, Dockerty MB, Waugh JM. A clinico-pathologic study of the epiploic appendages. Surg Gynecol Obstet 1956;103:423-4.

8. Boardman J, Kaplan KJ, Hollcraft C, Bui-Mansfield LT. Torsion of the epiploic appendage. Am J Roentgenol 2003;180:748. 9. Hanson JM, Kam AW. Paracolic echogenic mass in a man with lower abdominal pain. Is epiploic appendagitis more common than previously thought? Emerg Med J 2006;23:17.

10. Danielson K, Chemin MM, Amberg JR, et al. Epiploic appendicitis: CT characteristics. J Comput Assist Tomogr 1986; 10: 142-3.

11. Boulanger BR, Barnes S, Bernard AC. Epiploic appendagitis: An emerging diagnosis for general surgeons. Am Surg 2002; 68:1022-5.

12. Vazquez-Frias JA, Castaneda P, Valencia S, Cueto J. Laparoscopie diagnosis and treatment of acute epiploic appendagitis with torsion and necrosis causing an acute abdomen. JSLS 2000;4:247- 50.

VIJAYKUMAR G. PATEL, M.B., B.S., F.R.C.S., F.R.C.S.(ED)., F.A.C.S.,* ARUNDATHI RAO, M.D.,* REGINALD WILLIAMS, M.D.,* RADHA SRINIVASAN, M.D.,t JAMES K. FORTSON, M.D., F.A.C.S.,* WILLIAM L. WEAVER, M.D., F.A.C.S.*

From the *Department of Surgery, Morehouse School of Medicine and tSouth Fulton Medical Center,

Atlanta, Georgia

Presented during Poster Grand Rounds at the Annual Scientific Meeting and Postgraduate Course Program, Southeastern Surgical Congress, Savannah, GA, February 10-13, 2007.

Address correspondence and reprint requests to Vijaykumar G. Patel, M.B., B.S., F.R.C.S., F.R.C.S.(Ed), F.A.C.S., Associate Professor of Surgery, Department of Surgery, Morehouse School of Medicine, 720 Westview Drive, SW, Atlanta, GA 30311. E-mail: vpatel@msm.edu.

Copyright Southeastern Surgical Congress Aug 2007

(c) 2007 American Surgeon, The. Provided by ProQuest Information and Learning. All rights Reserved.