Epiploic Appendagitis
Gastrointestinal
Context
- Epiploic appendages or appendix epiploica are peritoneum-lined, fat-filled outpouchings arising from the surface of the colon attached to the external surface by vascular stalks that can become twisted, or stretched leading to venous infarction/necrosis.
- Can mimic various underlying causes of abdominal conditions.
- True incidence unknown, but 2 – 7% of patients suspected of having acute diverticulitis and 0.3-1% of patients suspected of having acute appendicitis have had acute appendagitis.
- In a case series of 58 patients, 57% of cases were in the rectosigmoid and 26% in the ileocecum.
- In emergency medicine, the significance of epiploic appendagitis is to differentiate this benign and self-limited condition from complex diverticulitis, appendicitis, or another intrabdominal emergency and to minimize unnecessary invasive interventions.
Diagnostic Process
- Present with acute onset lower abdomen pain, most commonly in the left lower quadrant and is constant, dull, and does not radiate. They are typically afebrile and have no rebound tenderness on physical exam.
- Typically, the pain will suddenly occur after movements that could potentially affect the underlying anatomy involved, such as postprandial activity or physical exercise.
- Laboratory values are usually normal but may indicate a mildly elevated WBC/CRP.
- Diagnosis is usually made by CT or abdominal ultrasound.
- Classic CT finding is an oval, fat-dense 2 – 3 cm paracolic mass with surrounding inflammatory changes such as peritoneal thickening and fat stranding. Normal, non-inflamed epiploic appendages are not seen on CT.
- Pathognomonic ultrasound findings – an oval-shaped, non-compressible, highly echogenic mass with a faint hypoechoic rim located directly beneath the area of greatest pain, without any visible central blood flow on color Doppler.
Recommended Treatment
- Epiploic appendagitis is benign and self-limited resolving spontaneously within 3 – 14 days.
- Recurrence and complications such as abscess formation or obstruction are thought to be very rare.
- Oral anti-inflammatory/analgesic medications and if necessary, short course of opioids.
- Antibiotics and hospitalization are not required.
- If there are complications or significant worsening of the symptoms, surgical consultation can be considered, however is the rarely needed
Quality Of Evidence?
High
We are highly confident that the true effect lies close to that of the estimate of the effect. There is a wide range of studies included in the analyses with no major limitations, there is little variation between studies, and the summary estimate has a narrow confidence interval.
Moderate
We consider that the true effect is likely to be close to the estimate of the effect, but there is a possibility that it is substantially different. There are only a few studies and some have limitations but not major flaws, there are some variations between studies, or the confidence interval of the summary estimate is wide.
Low
When the true effect may be substantially different from the estimate of the effect. The studies have major flaws, there is important variations between studies, of the confidence interval of the summary estimate is very wide.
Justification
There are a variety of studies available on this topic that have little variation in recommendations, but most studies are individual case reports or small case series. Therefore, the quality of this evidence is moderate.
Related Information
Reference List
Schnedl, W. J., Krause, R., Tafeit, E., Tillich, M., Lipp, R. W., & Wallner-Liebmann, S. J. (2011). Insights into epiploic appendagitis. Nature reviews. Gastroenterology & hepatology, 8(1), 45–49. https://doi.org/10.1038/nrgastro.2010.189
Rioux, M., & Langis, P. (1994). Primary epiploic appendagitis: clinical, US, and CT findings in 14 cases. Radiology, 191(2), 523–526. https://doi.org/10.1148/radiology.191.2.8153333
Sajjad Z., Sajjad N., Friedman M., Atlas S.A. (2000). Primary epiploic appendagitis: an etiology of acute abdominal pain, Conn Med, 64(11):655-7.
Singh A.K., Gervais D.A., Hahn P.F., Sagar P., Mueller P.R., Novelline R.A. (2005). Acute epiploic appendagitis and its mimics. Radiographics, 25(6):1521-34
Radiographic imaging: https://radiopaedia.org/articles/epiploic-appendage
DISCLAIMER
The purpose of this document is to provide health care professionals with key facts and recommendations for the diagnosis and treatment of patients in the emergency department. This summary was produced by Emergency Care BC (formerly the BC Emergency Medicine Network) and uses the best available knowledge at the time of publication. However, healthcare professionals should continue to use their own judgment and take into consideration context, resources and other relevant factors. Emergency Care BC is not liable for any damages, claims, liabilities, costs or obligations arising from the use of this document including loss or damages arising from any claims made by a third party. Emergency Care BC also assumes no responsibility or liability for changes made to this document without its consent.
Last Updated Oct 10, 2023
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