Epiploic Appendagitis

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

The large and small intestines.

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 an out-pouching on the outside wall of the bowels, whose function or purpose remains unknown. They are referred to as epiploic appendage.

In some individuals, they have been reported 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 twist along their long axis or if their blood supply gets blocked, they could cause a great deal of abdominal 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 the 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 central or lower abdominal pain, described by many as between 8 to 10 out of 10 in degree of severity.
• 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 can lead to an inflammation of the epiploic appendages, causing an 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, an infection that started as a local bowel issue 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 appendix epiploica, or blood vessel 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 not a newly described or recognised disorder. Contrary to what some in the medical field thinks, it is not "only recently been recognized".

It is believed to have been first recognized and reported in the 1850s.  The name epiploic appendagitis was first used in 1956 by Lynn et al to describe this condition.

There has been numerous reference to this condition ever since and for some 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 symptom of epiploic appendagitis is that of an acute lower right or left abdominal pain. Sometimes, patients with this condition could also develop a upper right side abdominal pain.

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, 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
• Severe pain, but usually without fever (though a very mild fever has been reported in a number of patients diagnosed with this condition), nausea or vomiting and 
• 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 scan, though in the past this condition is only diagnosed either during operation to remove a supposed bad appendix or at laparoscopy. The main findings on CT scan include fat inflammation around the colon, stranding of anti-mesenteric fat without associated bowel wall thickening. In many cases, these signs would be seen if a previously reported CT scan is reviewed.

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

Where facilities for a 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 usually a self limiting condition - that means that it gets better on its own, without the need for any treatment.

Once the diagnosis of this condition is made, treatment involves the use of anti-inflammatory painkillers like ibuprofen or Naproxen and adequate fluid replacement through intravenous drips if severe and rest.

Because appendagitis epiploica does not require treatment in most cases, it is therefore very important to make the right diagnosis and avoid unnecessary bowel surgery with its potential risks.

Very rarely, an inflamed epiploic appendage may develop abscess, needing intravenous antibiotics and in very small cases, surgery. Such cases are so remotely rare enough that it is only mentioned here 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.
• Uptodate.com

Last Updated: 18th January 2017.

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