Download Recurrent epiploic appendagitis mimicking

Recurrent epiploic appendagitis mimicking appendicitis
and cholecystitis
Claudia Lorente, MSc, Christopher B. Hearne, MD, and Jorge Taboada, MD
Epiploic appendagitis (EA) is a rare cause of acute abdominal pain
caused by inflammation of an epiploic appendage. It has a nonspecific
clinical presentation that may mimic other acute abdominal pathologies
on physical exam, such as appendicitis, diverticulitis, or cholecystitis.
However, EA is usually benign and self-limiting and can be treated conservatively. We present the case of a patient with two episodes of EA,
the first mimicking acute appendicitis and the second mimicking acute
cholecystitis. Although recurrence of EA is rare, it should be part of
the differential diagnosis of acute, localized abdominal pain. A correct
diagnosis of EA will prevent unnecessary hospitalization, antibiotic use,
and surgical procedures.
E
piploic appendagitis (EA) is a rare cause of acute abdominal pain that is usually benign and self-limiting
and can be treated conservatively with analgesics and
antiinflammatory medications (1–3). Recurrence of EA
is rare, and documented cases describe abdominal pain recurring
at the same location (3–5). We describe the case of a patient
with two episodes of EA, the first mimicking acute appendicitis
and the second mimicking acute cholecystitis.
CASE REPORT
A 66-year-old Caucasian woman presented with a 3-day
history of progressively worsening right mid abdominal pain
exacerbated by positional change. On a pain scale of 1 to 10,
she rated the pain an 8. She had some degree of anorexia, but
denied any associated chills, fever, nausea, vomiting, change in
bowel habits, or skin rash. Her past medical history included hypertension, hyperlipidemia, hypothyroidism, and stress-induced
cardiomyopathy. Her only abdominal surgeries consisted of
C-sections. Two years prior, she had a colonoscopy showing
no diverticulosis or significant polyps. Her family history was
significant for gallbladder disease requiring cholecystectomies.
On physical examination, she was ambulatory and not in
acute distress. She was afebrile, nonicteric, had normal vital
signs, and had a body mass index (BMI) of 30 kg/m2. Abdominal exam revealed tenderness with some degree of guarding
along the right flank. Bowel sounds were present. The differential diagnosis included retrocecal appendicitis and EA. The
complete blood count and comprehensive metabolic panel
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were normal. Computed tomography (CT) findings, shown
in Figure 1, were diagnostic for EA. The patient was treated with
analgesics and antiinflammatory medication. Her symptoms
resolved after 2 days of treatment.
She returned 19 months later with a 2-day history of constant sharp right upper quadrant pain aggravated by movement and similar in quality and severity to the pain she had
experienced during her diagnosis of EA months earlier, this
time without associated anorexia. The pain radiated towards the
epigastric region. On physical examination she appeared uncomfortable, pressing her hand against her right subcostal region.
She had normal vital signs, and her BMI was now 28 kg/m2
after dieting. Key findings on physical exam were point tenderness in the right upper quadrant with a positive Murphy sign.
A positive Murphy sign increases the likelihood of an inflamed
gallbladder and occurs when the patient arrests inspiration as
the examiner palpates the abdominal right upper quadrant while
the patient is taking a deep breath. The differential diagnosis
included acute cholecystitis and recurrent EA. Her complete
blood count, comprehensive metabolic panel, and lipase levels
were normal. Abdominal ultrasonography showed a normal
gallbladder, liver, and pancreas. Once again, the CT scan was
diagnostic (Figure 2), showing a mass of similar size and location as the previous EA lesion. The patient was treated with
analgesics and antiinflammatory medication, and her symptoms
resolved within 5 days.
DISCUSSION
Epiploic appendages are 50 to 100 pedunculated peritoneal
fat pouches oriented in two rows parallel to the taenia coli
of the colon, between the cecum and rectosigmoid junction,
each usually 1 to 2 cm thick and 0.5 to 5 cm long (3). Each
epiploic appendage is supplied by two endarteries, originating
from the vasa recta, and one single tortuous vein that passes
through a narrow stalk at its base (3). The peduncular shape and
From the Department of Internal Medicine (Hearne) and Department of Radiology
(Taboada), Baylor Scott & White Health; and the Texas A&M Health Science Center
College of Medicine (Lorente).
Corresponding author: Claudia Lorente, MSc, College of Medicine, Texas A&M
Health Science Center, 3950 North A. W. Grimes Blvd., Round Rock, TX 78665
(e-mail: [email protected]).
Proc (Bayl Univ Med Cent) 2017;30(1):44–46
a
b
Figure 1. (a) Axial and (b) coronal CT images. The oval-shaped inflamed epiploic appendage (2.4 × 1.4 cm) which has fat attenuation is outlined by the peripheral
rim of hyperattenuation (white arrows). Outside the borders of the appendage, surrounding fat stranding (black arrows) is seen. On the coronal image, a central dot
of high attenuation is present, likely representing a thrombosed vein.
narrow vascular supply stalk makes epiploic appendages prone
to torsion, leading to ischemic or hemorrhagic infarction, and
susceptible to venous thrombosis (3).
Primary EA is a rare cause of acute abdominal pain thought
to be caused by appendage torsion or venous thrombosis (3).
In a case series of 58 patients with EA, 48% of cases occurred
in the sigmoid colon, 28% in the descending colon, 7% in the
transverse colon, and 17% in the ascending colon (6). Thus,
EA often presents with lower abdominal pain mimicking diverticulitis and appendicitis, and there are few documented
presentations that mimic cholecystitis (7, 8). Secondary EA
results from inflammation of an adjacent organ, such as cholecystitis, pancreatitis, diverticulitis, or appendicitis (5, 9). These
infarcted appendages undergo fat necrosis and calcify and may
either stay attached to the colon or detach to become peritoneal
loose bodies or “parasitized epiploic appendages” by reattaching
to surfaces within the abdominal cavity, like the spleen (3).
a
Primary EA clinically presents as an abrupt onset of acute,
well-localized, nonmigratory abdominal pain, often in the lower
abdominal quadrants, that worsens with movement. The patient
usually is afebrile without nausea, vomiting, anorexia, or change
in bowel function (3, 6). On physical examination the patient
presents with localized tenderness and possible guarding. Usually vital signs and laboratory values are within normal limits,
but mild leukocytosis and slight elevation of C-reactive protein
have been reported in some cases (1, 3, 4).
EA is diagnosed via CT scan (preferred) and ultrasonography
(6, 9). In CT, the inflamed epiploic appendage usually appears
as a 1.5-cm to 3.5-cm fat-attenuation lesion adjacent to the
colon with a peripheral rim of hyperattenuation (representing
inflamed peritoneum), usually with a central dot of high attenuation (representing the thrombosed vein), with surrounding fat
stranding (representing increased edema), and with asymmetric
wall thickening of the colon, due to the inflammation being
b
Figure 2. (a) Axial and (b) coronal CT images obtained 19 months after the initial study. Either the same or a neighboring epiploic appendage (2.0 × 2.5 cm) anterior
to the ascending colon is inflamed, with a peripheral rim of hyperattenuation (white arrows) with surrounding inflammatory changes.
January 2017
Recurrent epiploic appendagitis mimicking appendicitis and cholecystitis
45
greater in the area surrounding the colon than on the colon wall
itself (6, 9). Omental infarctions and mesenteric panniculitis
may have clinical presentations similar to that of EA, but can
be distinguished from EA on CT because omental infarctions
usually are larger than 5 cm and lack a hyperattenuating rim
(9), and mesenteric panniculitis appears as a fat-attenuation
lesion within the mesentery usually with a “fat-ring sign,”
which represents preserved noninflamed fat around vessels (9).
Ultrasonography identifies an inflamed epiploic appendage as
a noncompressible hyperechoic mass adjacent to the colon wall
at the site of pain usually with a hypoechoic rim, representing
inflamed peritoneum, and absence of blood flow on Doppler
due to torsion or thrombosis (9).
Before CT scans were established as standard diagnostic
imaging tools, EA was a surgical diagnosis treated by laparoscopic surgical excision. However, EA is considered a benign,
self-limiting lesion that usually resolves spontaneously within
days to weeks and can be treated conservatively with over-thecounter analgesics and antiinflammatory medications (1, 2).
Rarely, surgical interventions are needed due to complications,
such as small bowel obstruction due to adhesions or external
compression (6).
Recurrence of EA is rare, but has been documented in cases
managed conservatively. In a case study of 10 patients with EA
treated conservatively, Sand et al observed recurrence of EA in 4
out of the 10 patients (3). Recurrence was also observed in a case
report of one patient on peritoneal dialysis (4). Authors of both
articles suggest involvement of the same epiploic appendage in
both presentations and recommend considering laparoscopic excision for these cases. Only one case report described recurrence
of EA involving two distinct epiploic appendages, both with
similar presentation and treated by laparoscopic excision due
to severe symptoms (5). Even though surgical excision would
remove the inflamed epiploic appendage that is causing irritation, the benefit of surgical excision should be weighed against
its risks—mainly anesthesia complications, excessive bleeding,
and infection—and cost (1–3).
The patient in this report had two occurrences of EA, each
with similar clinical presentation but eliciting pain in different
abdominal quadrants, first with right flank pain, mimicking
retrocecal appendicitis, and later in the right upper quadrant,
mimicking acute cholecystitis. Possible risk factors for develop-
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ing EA are obesity and postprandial strenuous exercise, supported by some case reports (7, 10) but not by others (3). From
the patient’s past medical history, only obesity (BMI >30 kg/m2)
during the first episode of EA and being overweight (BMI 25–
29.9 kg/m2) during the second episode could predispose her
for developing EA. CT scans taken in each instance found an
inflamed epiploic appendage of similar dimensions in the ascending colon adjacent to the hepatic flexure. The recurrent EA
could be due to involvement of the same epiploic appendage in
both presentations, causing pain in different quadrants because
the colon has some range of mobility within the abdominal cavity, or it could be due to involvement of a neighboring epiploic
appendage.
EA should be part of the differential diagnosis of acute abdominal pain because it is a benign, self-limiting lesion that
can be diagnosed with CT and treated conservatively. Correct
diagnosis avoids unnecessary hospitalizations, antibiotic treatment, and surgeries.
1.
Schnedl WJ, Krause R, Wallner-Liebmann SJ, Tafeit E, Mangge H, Tillich
M. Primary epiploic appendagitis and successful outpatient management.
Med Sci Monit 2012;18(6):CS48–CS51.
2. Rao PM, Rhea JT, Wittenberg J, Warshaw AL. Misdiagnosis of primary
epiploic appendagitis. Am J Surg 1998;176(1):81–85.
3. Sand M, Gelos M, Bechara FG, Sand D, Wiese TH, Steinstraesser L,
Mann B. Epiploic appendagitis—clinical characteristics of an uncommon
surgical diagnosis. BMC Surg 2007;7:11.
4. Shrestha B, Hampton J. Recurrent epiploic appendagitis and peritoneal
dialysis: a case report and literature review. World J Nephrol 2014;3(3):
114–117.
5. Marschall J, Karimuddin A, Hayes P. Soft-tissue case 44. Recurrent
epiploic appendagitis. Can J Surg 2002;45(2):93:154–155.
6. Patel NB, Wenzke DR. Evaluating the patient with right lower quadrant
pain. Radiol Clin North Am 2015;53(6):1159–1170.
7. Lien WC, Lai TI, Lin GS, Wang HP, Chen WJ, Cheng TY. Epiploic
appendagitis mimicking acute cholecystitis. Am J Emerg Med 2004;22(6):
507–508.
8. Maillet JM, Thierry S, Sverzut JM, Brodaty D. An unusual cause of acute
abdominal pain after cardiac surgery: acute epiploic appendagitis. Interact
Cardiovasc Thorac Surg 2012;15(2):292–293.
9. Almeida AT, Melão L, Viamonte B, Cunha R, Pereira JM. Epiploic
appendagitis: an entity frequently unknown to clinicians—diagnostic
imaging, pitfalls, and look-alikes. AJR Am J Roentgenol 2009;193(5):
1243–1251.
10. Ortega-Cruz HD, Martínez-Souss J, Acosta-Pumarejo E, Toro DH. Epiploic appendagitis, an uncommon cause of abdominal pain: a case series
and review of the literature. P R Health Sci J 2015;34(4):219–221.
Baylor University Medical Center Proceedings
Volume 30, Number 1