an uncommon cause of acute abdomen - epiploic appendagitis: ct

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INTRODUCTION Epiploic appendages are fat- and blood vessel-con- taining outpouchings protruding from the serosal surface of the colon (1-3). They appear in the fifth month of fetal life (2) and in an adult human, the average number of epiploic appendages is approxi- mately 50-100. They measure from 2-5 cm in length (1, 2, 4). Vessels pass through their narrow pedicle. Epiploic appendagitis is the inflammatory process of the epiploic appendage and has primary and secondary types. Primary epiploic appendagi- tis (PEA) is the infarction and inflammation of an appendage because of torsion or spontaneous ve- nous thrombosis. PEA mimics acute abdominal di- seases; thus, it must be distinguished from the se- condary epiploic appendagitis, which is caused by neighborhood inflammatory processes such as di- verticulitis, appendicitis or cholecystitis (1, 2). Computed tomography (CT) features distinguish epiploic appendagitis from other inflammatory conditions by measuring the fat tissue density wit- hin the mass (2). Although the findings are speci- fic, they are demonstrated rarely. In this paper, we present two cases of epiploic appendagitis with characteristic CT findings and their follow-up af- ter treatment. CASE REPORTS Case 1 A 25-year-old male patient was admitted to the emergency clinic with progressively increasing left lower quadrant pain and nausea of sudden onset. The pain increased with coughing and breathing. There was left lower quadrant tenderness with de- ep palpation on physical examination. The white Turk J Gastroenterol 2007; 18 (2): 107-110 Manuscript received: 01.02.2006 Accepted: 15.03.2007 Address for correspondence: Nihal USLU TUTAR Department of Radiology, Baflkent University Hospital, Fevzi Çakmak Cad. 10. Sk. No: 45 Bahçelievler, Ankara, Turkey Phone: +90 312 212 68 68 • Fax: +90 312 223 73 33 E-mail: nihalt@baskent–ank.edu.tr An uncommon cause of acute abdomen - epiploic appendagitis: CT findings Nadir akut kar›n nedenlerinden epiploik apandisit: BT bulgular› Nihal USLU TUTAR, Esra ÖZGÜL, Dilek O⁄UZ, Banu ÇAKIR, N. Ça¤la TARHAN, Mehmet COfiKUN Department of Radiology, Baflkent University, School of Medicine, Ankara Nadir akut kar›n nedenlerinden olan epiploik apandisit, epip- loik apendikslerin kendi kendini s›n›rlayan inflamasyonudur. Primer tipi nadirdir fakat bilgisayarl› tomografi bulgular› spe- sifiktir. Bu yaz›da, acil servise akut abdominal a¤r› ile gelen ve epiploik apandisit tan›s› konulan iki olgunun tomografi bulgu- lar› sunulmaktad›r. ‹ki olguda da tedavi öncesi çekilen bilgisa- yarl› tomografide solda inen kolon komflulu¤unda, intravenöz kontrast madde enjeksiyonu sonras›nda periferal kontrastlan- ma gösteren ya¤ dansitesinde nodüler lezyon mevcuttu. Lezyon çevresinde mezenterik ya¤ dokuda inflamasyona sekonder dan- site art›fllar› izlendi. Olgulara, tomografi bulgular›na göre epiploik apandisit tan›s› kondu. Tedaviden 1.5-3 ay sonra çeki- len kontrol bilgisayarl› tomografide bulgular›n kayboldu¤u ve klinik iyileflme ile korele oldu¤u izlendi. Anahtar kelimeler: ‹nflamasyon, epiploik apendiks, akut kar›n, kolon, bilgisayarl› tomografi Epiploic appendagitis, which is an uncommon cause of acute abdomen, is a benign self-limiting inflammatory process of epiploic appendices. It has primary and secondary types. Com- puted tomography findings of the primary type are specific but are demonstrated rarely. Herein, we present pre- and post-treat- ment computed tomography findings of two cases who admitted to the emergency clinic with acute abdominal pain and were di- agnosed to have epiploic appendagitis. Follow-up computed to- mography features correlated well with clinical improvement. Key words: Inflammation, epiploic appendage, acute abdomen, colon, computed tomography

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Page 1: An uncommon cause of acute abdomen - epiploic appendagitis: CT

INTRODUCTION

Epiploic appendages are fat- and blood vessel-con-taining outpouchings protruding from the serosalsurface of the colon (1-3). They appear in the fifthmonth of fetal life (2) and in an adult human, theaverage number of epiploic appendages is approxi-mately 50-100. They measure from 2-5 cm inlength (1, 2, 4). Vessels pass through their narrowpedicle. Epiploic appendagitis is the inflammatoryprocess of the epiploic appendage and has primaryand secondary types. Primary epiploic appendagi-tis (PEA) is the infarction and inflammation of anappendage because of torsion or spontaneous ve-nous thrombosis. PEA mimics acute abdominal di-seases; thus, it must be distinguished from the se-condary epiploic appendagitis, which is caused byneighborhood inflammatory processes such as di-verticulitis, appendicitis or cholecystitis (1, 2).

Computed tomography (CT) features distinguishepiploic appendagitis from other inflammatoryconditions by measuring the fat tissue density wit-hin the mass (2). Although the findings are speci-fic, they are demonstrated rarely. In this paper,we present two cases of epiploic appendagitis withcharacteristic CT findings and their follow-up af-ter treatment.

CASE REPORTS

Case 1

A 25-year-old male patient was admitted to theemergency clinic with progressively increasing leftlower quadrant pain and nausea of sudden onset.The pain increased with coughing and breathing.There was left lower quadrant tenderness with de-ep palpation on physical examination. The white

Turk J Gastroenterol 2007; 18 (2): 107-110

Manuscript received: 01.02.2006 Accepted: 15.03.2007Address for correspondence: Nihal USLU TUTARDepartment of Radiology, Baflkent University Hospital, Fevzi Çakmak Cad. 10. Sk. No: 45 Bahçelievler, Ankara, TurkeyPhone: +90 312 212 68 68 • Fax: +90 312 223 73 33E-mail: nihalt@baskent–ank.edu.tr

An uncommon cause of acute abdomen - epiploicappendagitis: CT findingsNadir akut kar›n nedenlerinden epiploik apandisit: BT bulgular›

Nihal USLU TUTAR, Esra ÖZGÜL, Dilek O⁄UZ, Banu ÇAKIR, N. Ça¤la TARHAN, Mehmet COfiKUN

Department of Radiology, Baflkent University, School of Medicine, Ankara

Nadir akut kar›n nedenlerinden olan epiploik apandisit, epip-loik apendikslerin kendi kendini s›n›rlayan inflamasyonudur.Primer tipi nadirdir fakat bilgisayarl› tomografi bulgular› spe-sifiktir. Bu yaz›da, acil servise akut abdominal a¤r› ile gelen veepiploik apandisit tan›s› konulan iki olgunun tomografi bulgu-lar› sunulmaktad›r. ‹ki olguda da tedavi öncesi çekilen bilgisa-yarl› tomografide solda inen kolon komflulu¤unda, intravenözkontrast madde enjeksiyonu sonras›nda periferal kontrastlan-ma gösteren ya¤ dansitesinde nodüler lezyon mevcuttu. Lezyonçevresinde mezenterik ya¤ dokuda inflamasyona sekonder dan-site art›fllar› izlendi. Olgulara, tomografi bulgular›na göreepiploik apandisit tan›s› kondu. Tedaviden 1.5-3 ay sonra çeki-len kontrol bilgisayarl› tomografide bulgular›n kayboldu¤u veklinik iyileflme ile korele oldu¤u izlendi.

Anahtar kelimeler: ‹nflamasyon, epiploik apendiks, akut kar›n,kolon, bilgisayarl› tomografi

Epiploic appendagitis, which is an uncommon cause of acuteabdomen, is a benign self-limiting inflammatory process ofepiploic appendices. It has primary and secondary types. Com-puted tomography findings of the primary type are specific butare demonstrated rarely. Herein, we present pre- and post-treat-ment computed tomography findings of two cases who admittedto the emergency clinic with acute abdominal pain and were di-agnosed to have epiploic appendagitis. Follow-up computed to-mography features correlated well with clinical improvement.

Key words: Inflammation, epiploic appendage, acute abdomen,colon, computed tomography

Page 2: An uncommon cause of acute abdomen - epiploic appendagitis: CT

out acute abdominal disease. CT demonstrated ahypodense lesion on the left side with fat densityand peripheral contrast enhancement next to thedescending colon and increased density of the me-senteric fat planes around the lesion, which wasthought to be secondary to inflammation. Accor-ding to these CT findings, epiploic appendagitis,secondary to inflammation of torsioned epiploicappendix, was diagnosed (Figure 1a, 1b). ControlCT scans three months after medical treatmentdemonstrated regression of the inflammatory fin-dings (Figure 1c).

Case 2

A 37-year-old male patient was admitted to theemergency clinic with intermittent suprapubic pa-in that later became constant and progressively lo-calized to the left lower quadrant. There was leftabdominal tenderness on physical examination;the laboratory findings were unremarkable. Abdo-minal ultrasonography showed no significant ab-normalities. Abdominal CT demonstrated hypo-dense nodular lesion having fat density on the leftside neighboring the descending colon. Increaseddensity secondary to inflammation was seen inmesenteric fat planes around the lesion. Lesionshowed peripheral contrast enhancement. In thiscase, inflammation around the fatty appendagewas more significant. Peritoneal thickening andcontrast enhancement according to the inflamma-tion were present in this case (Figure 2a, 2b).Epiploic appendagitis was diagnosed according tothe CT findings. After antibiotic therapy, follow-up CT scan six weeks later demonstrated no inf-lammation (Figure 2c).

DISCUSSION

Epiploic appendages appear in the fifth month offetal life (2). In an adult human, they number 50-100 on average, and their measurements rangefrom 2-5 cm in length (1, 2, 4). They generally ari-se from the descending colonic wall such that the-ir inflammation mimics diverticulitis.

In 1543, Vesalius first reported them as finger-li-ke projections of fat-containing structures arisingfrom the serosal surface of the colon. The vesselspass through their narrow pedicle which containsone or two small arteries and a single vein (4).

The role of epiploic appendages is still not clearlyknown, but there are some theories. They mayfunction as a barrier against infection or inflam-mation as a miniature omentum (4). Some authors

USLU TUTAR et al.108

Figure 1. a) Non-enhanced and, b) enhanced CT demonstrate

hypodense lesion on the left side, anterior to the descending co-

lon, and increased density of mesenteric fat planes around the le-

sion. The lesion had fat density centrally with peripheral contrast

enhancement, c) Follow-up non-enhanced CT scan shows reg-

ression of findings

cell count was normal. Abdominal MultidetectorCT (Volume Zoom, Siemens, Erlangen, Germany)with intravenous contrast was performed to rule

a

b

c

Page 3: An uncommon cause of acute abdomen - epiploic appendagitis: CT

close a perforation or protect a suture line duringsurgeries (5).

Epiploic appendagitis has primary and secondaryforms. Torsion or spontaneous venous thrombosiscauses inflammation and infarction of the appen-dage that result in PEA. Secondary epiploic ap-pendagitis is caused by nearby inflammatory pro-cesses like appendicitis, diverticulitis or cholecys-titis (1-5). It is important to distinguish betweenthe two in order to avoid unnecessary surgery inthe primary cases.

Patients generally have acute onset abdominal pa-in with left lower quadrant tenderness, which so-metimes increases with motion and deep breat-hing (2). Some patients report fever, vomiting, di-arrhea or nausea, such as our first case (1, 6). La-boratory findings are usually normal, or white blo-od cell count is minimally elevated (4, 6). Someti-mes exercise or posture change may cause PEA (2,4). Male predominance is seen in the primary formand it affects obese people in the second to fifth de-cades of life (4, 5).

Ultrasound has been used to show epiploic appen-dagitis. It shows hyperechoic noncompressiblemass near the colonic wall at the site of tender-ness on physical examination (1-4, 7-10). With co-lor Doppler, no vascularity is demonstrated withinthe mass, and this finding distinguishes it from ot-her inflammatory processes such as diverticulitisor appendicitis (1, 3).

CT findings of PEA are specific and characteristicfor epiploic appendagitis. In both of the presentedcases, abdominal CT demonstrated an oval fatdensity lesion on the left side with peripheral cont-rast enhancement next to the descending colonand increased density of mesenteric fat planesaround the lesion secondary to the inflammation,as presented in previous papers (1, 2, 7, 11, 12).Sometimes fascial thickening and nearby parietalperitoneal thickening may be demonstrated (1, 5,7, 8, 10, 11). A linear density according to thethrombosed vein may also be seen in the lesion.Adjacent colonic wall thickening and mass effecton the nearby bowel structures were also reportedby some authors in the literature (5). Omental in-farction is another entity that may mimic PEA.But location and limited small extension of PEAdistinguish it from omental infarction. The treat-ment is nonsurgical with antibiotics. In both ca-ses, significant regression of the findings was de-monstrated after treatment with non-contrast CT.

Epiploic appendagitis 109

Figure 2. a) Non-enhanced and b) contrast-enhanced CT scans

show pericolic inflammation neighboring the descending colon.

Fat tissue density within the inflammatory tissue is consistent

with epiploic appendage. Peritoneal thickening and contrast en-

hancement according to the inflammation nearby the lesion are

also present, c) Follow-up non-enhanced CT image demonstra-

ted normal findings without any inflammation

report that, by acting as cushions, they may pro-tect the colon during peristalsis or they may act asa depot of blood against the colonic intramuralvessel's contraction. Another theory is that theymay store fat (4, 5). Some surgeons use them to

a

b

c

Page 4: An uncommon cause of acute abdomen - epiploic appendagitis: CT

In conclusion, PEA mimics acute abdominal dise-ases, and CT findings are characteristic for the di-sease. It should be kept in mind that if the patientis diagnosed with this rare inflammatory conditi-

on, other acute pathologies can be excluded andunnecessary surgery in patients can be avoided.Precontrast CT is sufficient for the follow-up of thepatients.

USLU TUTAR et al.110

REFERENCES1. Hollerweger A, Macheiner P, Rettenbacher T, Gritzmann

N. Primary epiploic appendagitis: sonographic findingswith CT correlation. J Clin Ultrasound 2002; 30: 481-95.

2. Molla E, Ripolles T, Martinez MJ, et al. Primary epiploicappendagitis: US and CT findings. Eur Radiol 1998; 8: 435-8.

3. Danse EM, Van Beers BE, Baudrez V, et al. Epiploic ap-pendagitis: color Doppler sonographic findings. Eur Radiol2001; 11: 183-6.

4. Legome EL, Sims C, Rao PM. Epiploic appendagitis: ad-ding to the differential of acute abdominal pain. J EmergMed 1999; 17: 823-6.

5. Sirvanci M, Tekelioglu M, Duran C, et al. Primary epiploicappendagitis: CT manifestations. Clin Imaging 2000; 24:357-61.

6. Birjawi GA, Haddad MC, Zantout HM, Uthman SZ.Primary epiploic appendagitis: a report of two cases. ClinImaging 2000; 24: 207-9.

7. Mcclure M, Khalili K, Sarrazin J, Hanbidge A. Radiologicalfeatures of epiploic appendagitis and segmental omentalinfarction. Clin Radiol 2001; 56: 819-27.

8. Talukdar R, Saikia N, Mazumder S, et al. Epiploic appen-dagitis: report of two cases. Surg Today 2007; 37: 150-3.

9. Hoeffel C, Crema MD, Belkacem A, et al. Multi-detectorrow CT: spectrum of diseases involving the ileocecal area.Radiographics 2006; 26: 1373-90.

10. Ng KS, Tan AG, Chen KK, et al. CT features of primaryepiploic appendagitis. Eur J Radiol 2006; 59: 284-8.

11. Singh AK, Gervais DA, Hahn PF, et al. Acute epiploic ap-pendagitis and its mimics. Radiographics 2005; 25: 1521-34.

12. Kantarci M, Duran C, Sirvanci M. Images of interest.Gastrointestinal: epiploic appendagitis. J GastroenterolHepatol 2005; 20: 482.