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BMJ Case Rep. 2010; 2010: bcr08.2009.2171.
Published online 2010 April 22. doi:  10.1136/bcr.08.2009.2171
PMCID: PMC3047281
Rare disease

Appendicitis epiploicae: a rare cause of acute abdomen

Abstract

Acute appendicitis is one of the most common causes of right lower quadrant acute abdominal pain in adults. Some other conditions, including appendicitis epiploicae, can simulate an acute abdomen. Appendicitis epiploicae or epiploic appendicitis usually originates in the sigmoid colon and rarely from other parts of colon. We report a case of a 20-year-old man with appendicitis epiploicae of the caecum, who underwent surgery for acute appendicitis. Analysis of this uncommon condition, together with a review of the pertinent literature, are presented.

Background

Primary appendicitis epiploicae is a rare condition.1 Since the clinical presentation is not pathognomonic, the diagnosis is rarely performed preoperatively and is often confused with acute appendicitis.2 The majority of appendicitis epiploicae cases occur in the sigmoid colon of middle aged men suffering from acute abdominal pain of the left lower abdomen. Appendicitis epiploicae of the transverse colon and caecum may cause right upper and right lower quadrant pain, respectively. A correct preoperative diagnosis is essential because the patient can be treated conservatively to avoid unnecessary surgery; however, many authors suggest that the definitive treatment for appendicitis epiploica should be surgical excision.3

Case presentation

A 28-year-old woman with progressive right lower quadrant pain for 1 day presented to our emergency service. She had nausea but no vomiting. The physical examination revealed local tenderness and positive rebound in the right lower quadrant, but no general defence was detected. Axillary fever was 37°C, and the rectal examination was normal. The white blood cell count was 11.5×109/l. Total urine analyses and biochemical parameters were normal. Abdominal plain radiography was normal. At ultrasonography, the appendix could not be visualised clearly and there was free fluid between the intestinal loops. An urgent laparotomy with McBurney incision was performed following a preoperative diagnosis of appendicitis. The appendix was found to be intact perioperatively. Meckel diverticulum was not found and both ovaries and the uterus were normal. An oedematous and torsioned appendices epiploicae was observed on the caecum (fig 1), and appendicitis epiploicae was diagnosed. Surgical excision and an additional appendectomy was completed. The histological examination revealed fat necrosis, congestion and free bleeding areas for appendicitis epiploicae. The appendix was otherwise unremarkable. The patient was discharged on the third postoperative day, without presenting any postoperative complications.

Figure 1
An oedematous and torsioned caecal epiploicae appendicae observed in the caecum, and appendicitis epiploica was diagnosed (small arrow, appendicitis; large arrow, appendicitis epiploica).

Treatment

The treatment of appendicitis epiploicae is initially conservative, if diagnosed preoperatively. The surgical treatment of appendicitis epiploicae is simple ligation and excision if an intraoperative diagnosis is made.

Discussion

Appendicitis epiploicae is a rare entity. The relative incidence compared to acute vermiform appendicitis is 0.2%.4 Appendices epiploicae are pendulous adipose structures protruding from the serosal surface of the large intestine that are arranged in two separate longitudinal rows. Each of them is supplied by one or two small end arteries branching from the long vessels of the colon and drained by a tortuous vein passing through a narrow pedicle. Their limited blood supply, together with their peduncle shape and excessive mobility, make them prone to spontaneous torsion and ischaemic or haemorrhagic infarction.5 Appendices epiploicae may become infarcted as a result of venous thrombosis. The process of the inflammatory reaction that follows acute torsion or spontaneous thrombosis of the draining vein is called primary appendicitis epiploicae.6 Appendices epiploicae are also affected by calcification due to aseptic fat necrosis, pericolic abscess, enlargement by lipomas or metastases, and incarceration in hernias.7

The clinical presentation of an acute torsion can also mimic acute appendicitis, diverticulitis or cholecystitis.8 Symptoms may be minimal and there is no diagnostic sequence of symptoms. The most common presenting symptom is acute, moderate to severe, colicky or continuous abdominal pain in an area corresponding to the contour of the colon, and pain shift is unusual. The pain is usually present for less than a week, but in some patients it may occur intermittently over several months.1 The patient does not look ill, nausea and vomiting are unusual, and appetite is commonly unaffected. Localised tenderness over the site is usual and is often associated with pronounced rebound tenderness without rigidity.

Laboratory investigations have been found to be inconclusive, and usually suggest a normal or slightly elevated leucocyte count.2,3 The radiological evaluation in the form of abdominal ultrasound examination and computed tomography (CT) scan has been found to be useful in the preoperative diagnosis in patients with appendicitis epiploicae. A review of the literature suggests that the presence of a hyperechoic non-compressible ovoid structure near the colonic wall with the absence of blood flow on sonographic assessment of the abdomen provides the clue to the diagnosis.2 Similarly, CT scan has been found to be useful both for preoperative diagnosis and for further assessment in patients managed conservatively. As stated above, a correct preoperative diagnosis is rarely made.9 There are no pathognomonic features of primary appendicitis epiploicae, and it may be encountered by the surgeon while performing a laparotomy for another condition.1 The treatment of choice for primary appendicitis epiploicae consists of simple ligation and excision.9 If a preoperative diagnosis is made, conservative treatment with antibiotics and analgesics seems to be safe.2

Learning points

  • Appendicitis epiploicae is a rare entity.
  • Appendicitis epiploicae is often diagnosed by the surgeon while performing a laparotomy for another condition.
  • The torsion of appendices epiploicae may be seen in all the colonic segment, but it usually originates from the sigmoid colon and rarely from the caecum.
  • The treatment of appendicitis epiploicae is initially conservative, if diagnosed preoperatively. If an intraoperative diagnosis is made, the surgical treatment of appendicitis epiploicae is simple ligation and excision.

Footnotes

Competing interests: None.

Patient consent: Patient/guardian consent was obtained for publication.

REFERENCES

1. Lynn TE, Docherty MB, Waugh JM. A clinicopathological study of the epiploic appendages. Surg Gynec Obstet 1956; 103: 423–33. [PubMed]
2. Hurreiz HS, Madavo CM. Torsion of an epiploic appendix mimicking acute appendicitis. Saudi Med J 2005; 26: 2003–4. [PubMed]
3. Christianakis E, Paschalidis N, Filippou G, et al. Cecal epiploica appendix tortion in a female child mimicking acute appendicitis: a case report. Cases Journal 2009; 2: 8023. [PMC free article] [PubMed]
4. Bearse C. Primal affections of appendices epiploicae. Am J Dig Dis 1952; 19: 22–4. [PubMed]
5. Pereira JM, Sirlin CB, Pinto PS, et al. Disproportionate fat stranding: a helpful CT sign in patients with acute abdominal pain. Radio Graphics 2004; 24: 703–15. [PubMed]
6. Horvath EV, Majlis SD, Saguel SB, et al. Primary epiploic appendagitis. Clinical and radiological diagnosis. Rev med Chile 2000; 128: 601–7. [PubMed]
7. Singh AK, Gervais DA, Hahn PF, et al. CT appearance of acute appendagitis. AJR Am J Roentgenol 2004; 183: 1303–7. [PubMed]
8. Shirokikh VV. [Torsion of an epiploic appendage of the transverse colon simulating acute cholecystitis]. Vestn Khir Im I I Grek 1972; 109: 102–3. [PubMed]
9. McMahon AJ, Hansell DT. Primary appendicitis epiploicae mimicking acute appendicitis. Postgrad Med J 1988; 64: 903–5. [PMC free article] [PubMed]

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