Epiploic Appendagitis

What Is Epiploic Appendagitis, What Causes It, And How Is This Condition Diagnosed And Treated?


Epiploic appendagitis, also referred to as appendicitis epiploica or epiplopericolitis is the inflammation, or torsion of one or a couple of the hundred or so small protrusions of fatty tissue on the outside wall of the large intestine or colon. It is a common cause of sudden onset abdominal pain often mistaken for appendicitis and other conditions. Find out how to differentiate this condition from other causes of abdominal pain and how it is treated here.

Epiploic Appendagitis Can Be Found On The Wall Of The Colon

On the outside wall of our colon or large intestine, there are about 100 or so protrusions made up of fat and tissues covering the colon. They could be as small as half a centimeter to three centimeters in length on the average, pointing perpendicularly away from the colon. These structures are out-pouching on the outside wall of the bowels, whose function or purpose is not known and are referred to as epiploic appendage. In some individuals, they have been recorded to be as long as 15cm! They have blood vessels supplying nutrient to them.

If, for any reason they become inflamed from the spread of a bowel infection, or they undergo torsion and twist along their long axis or if their blood supply gets blocked, they could lead to a terrible degree of pain.

What Are The Causes Of Epiploic Appendagitis?

As mentioned above, one of three events could lead to the development of inflammation of the epiploic appendage, or appendicitis epiploica. These are:

  • Torsion Of One Or More Epiploic Appendage. In individuals with large or longer than usual epiploic appendage, because of the difference in angle in which the vein and artery enters and leave the appendage, they are prone to getting kinked or twisted. Should one or more of an unusually large appendage become twisted, this may lead to a sudden onset severe abdominal pain, described by many as between 8 -10 out of 10 on severity scaling.
  • Blockade Of Blood Supply To The Epiploic Appendage. In patients who suffer with circulation problems, or following a heart or bowel operation, or in those prone to blood clot formation, a small blood clot could get trapped in the blood vessel supplying these appendages. If this happens, it leads to inflammation of the epiploic appendages, presenting as insidious onset abdominal pain which could last for days before it resolves.
  • Spread of Bowel Inflammation Or Infection To The Appendages. In some patients with ongoing infection or inflammation of the large bowel, this could spread to involve the epiploic appendages and cause inflammation in these structures. An example is following exacerbation of an inflammatory bowel disease like crohn's disease or ulcerative colitis or after bouts of diarrhoea from gut infection.

Appendicitis epiploica arising from torsion of the appndix epiploica, or blood vessle blockade or kinking are referred to as primary appendagitis, while those arising from spread of infection or inflammation somewhere else are referred to as secondary appendagitis.

Symptoms Of Epiploic Appendage Infection

Epiploic appendagitis is by no means a new concept. Contrary to what some in the medical field thinks, it is not "only recently been recognized". It is believed to have been first described in the 1850s and the name epiploic appendagitis was first used in 1956 by Lynn et al to describe this condition. There has been numerous documentations of this condition ever since and for some unknown reasons, many doctors have not embraced this important, though relatively uncommon cause of abdominal pain.

It is estimated that for every 100 diagnosis of appendicitis made, one of such cases is actually due to appendagitis, and for every 100 cases of suspected diverticulitis, up to 7 are due to inflammation of the epiploic appendage.

The most common way those with epiploic appendagitis present is with symptoms of acute lower right or left abdominal pain. Sometimes, a upper right side abdominal pain could be due to epiploic appendage inflammation or torsion. Over half (53%) of epiploic appendagitis occurs on the lower left abdominal region.

Conditions that can be mimicked by appendicitis epiploica include:

  • Diverticulitis
  • Acute Appendicitis
  • Cholecystitis
  • Omental Infarction
  • Mesenteric Panniculitis

If you develop sudden onset upper or lower right or left side abdominal pain and have had tests and all the blood results and scans came back normal and yet still having pain, epiplopericolitis could be the cause.

How Is This Condition Diagnosed?

The diagnosis of appendicitis epiploica is usually made from a combination of the story or history given by the patient of:

  • Lower Left abdominal pain which may be of gradual or sudden onset
  • Or Lower right abdominal pain resembling that of appendicitis
  • Or Upper right or left abdominal pain
  • Pain could be very severe, but usually without fever (though a very mild fever has been reported in a number of patients diagnosed with this condition), nausea or vomiting
  • All other common causes of abdominal pain has been excluded
  • Blood and urine tests normal including normal white blood cells
  • Ultrasound scan normal
  • CT scan could be reported to be normal, if the radiologist did not actually look out for the CT signs of epiplopericolitis.

The diagnosis is usually made on CT these days, though in the past this condition is only diagnosed either during operation to removed a supposed bad appendix or at laparoscopy. The main findings on CT scan include fat inflammation around the colon, stranding of antimesenteric fat without associated bowel wall thickening. In many cases, these signs would be seen if a previously reported Ct scan is reviewed.

The CT Scan Findings In Epiploic Appendagitis

If looked for, the CT findings in epiploic appendagitis include:
  • A one to four centimeter oval shaped fat attenuated lesion (often with fat hyper-attenuated rim)around the colon with fat stranding around the epilpoic appendage and thickened visceral peritoneal lining
  • A central area or central dot can be seen in the appendiceal mass in over half of the cases
  • The oval fat dense lump could show some lobulations.

"As CT increasingly is used for the evaluation of acute abdomen, radiologists are likely to see acute epiploic appendagitis and its mimics more often. Recognition of these conditions on CT images will allow appropriate management of acute abdominal pain and may help to prevent unnecessary surgery." - Radiographics, a scientific journal of radiology of November - December 2005

Where facilities for CT scan does not exist, an abdominal ultrasound scan may show an "oval hyperechoic mass surrounded by a hypoechoic rim, without Doppler flow", reports the Canadian Medical Association Journal, CMAJ. 2010 June 15; 182(9): 939.

Treatment of Appendicitis Epiploica

Epiploica appendagitis is a self limiting condition - that means that it gets better on its own, without the need for ant treatment. Usually, once the diagnosis is made, treatment involve the use of anti-inflammatory pain killers like ibuprofen and adequate fluid replacements and rest.

It is because this condition does not need treatment in greater percentage of cases, that it is important to make the right diagnosis and avoid unnecessary operation with its attendant surgical and anesthetic risks.

Very very rarely, an inflamed epiploic appendage may develop abscess, needing intravenous antibiotics and in severe cases surgery. But such cases are remotely rare enough that they are only mentioned for completeness sake.

References:

  • Baadh AS,Singh S,Graham RE. A Mysterious Cause of a Surgical Abdomen. The Journal of Emergency Medicine, 07 August 2012, 0736-4679.
  • Philippe Leclercq, MD and Laurent Dorthu, MD. Epiploic appendagitis. CMAJ. 2010 June 15; 182(9): 939. doi: 10.1503/cmaj.090791.
  • Textbook: Practical Differential Diagnosis in CT and MRI By Eugene C. Lin, Edward J Escott, Kavita D Garg. Chapter 103, Page 236. Publication Date: June 18, 2008. ISBN-10: 1588906558.
  • Simren Sangha, Jorge A. Soto, James M. Becker, Francis A. Farraye. CASE REPORT: Primary Epiploic Appendagitis: An Underappreciated Diagnosis. A Case Series and Review of the Literature. Digestive Diseases and Sciences. February 2004, Volume 49, Issue 2, pp 347-350.

Last Updated: 3rd December 2012.

Think You Might Have Epiploic Appendage Inflammation? Share Your Experience

Had a sudden onset upper or lower quadrant abdominal pain recently and had blood tests, scans etc and told nothing was found? Are you one of the few lucky ones to be told you had epiploic appendage inflammation, thus avoided an unnecessary surgical operation, or perhaps do you think this condition might be the cause of your abdominal pain? We would love to hear from you. Share your experience with other readers here!

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