What is the treatment for epiploic appendagitis diagnosed on a CT (computed tomography) scan and is it safe to discharge from the Emergency Department (ED)?

Treatment of Epiploic Appendagitis and Safety of ED Discharge

Epiploic appendagitis diagnosed on CT scan should be treated conservatively with NSAIDs, and patients can be safely discharged from the Emergency Department with appropriate follow-up instructions.

Understanding Epiploic Appendagitis

Epiploic appendagitis is an uncommon cause of acute abdominal pain that results from inflammation, torsion, or venous thrombosis of epiploic appendages (fat-filled peritoneal pouches attached to the serosal surface of the colon) 1, 2.

• Epiploic appendagitis is frequently misdiagnosed as acute diverticulitis or appendicitis due to similar clinical presentation 1, 3
• It most commonly affects middle-aged adults, particularly those who are overweight 2
• The condition is self-limiting and benign in nature 4

Diagnostic Features on CT

CT scan is the primary diagnostic modality for epiploic appendagitis, with characteristic findings:

• Fat-density ovoid lesion with a hyperattenuating ring sign 1
• Mild bowel wall thickening 1
• Central high-attenuation focus within the fatty lesion (central dot sign) 1
• Oval fatty density solid lesion along anterior colonic wall surface, surrounded by a rim of fat stranding 4

Treatment Approach

Conservative Management

• First-line treatment consists of NSAIDs for pain control 2
• Antibiotics are not required as this is not an infectious process 4
• Symptoms typically resolve within a few days with conservative management 1

When to Consider Intervention

• Operative intervention is rarely needed and should only be considered if:
  • Symptoms persist despite conservative management 2
  • Complications arise (rare) 2

Emergency Department Management and Discharge

Safe for Discharge

• Patients with epiploic appendagitis can be safely discharged from the Emergency Department once the diagnosis is confirmed by CT scan 3
• Unlike acute appendicitis or diverticulitis, which may require hospitalization or surgical intervention, epiploic appendagitis is self-limiting 1, 3

Discharge Instructions

• Prescribe NSAIDs for pain control 2
• Educate patients about the benign, self-limiting nature of the condition 4
• Advise patients to return if symptoms worsen or fail to improve within 2-3 days 3
• Arrange appropriate outpatient follow-up 3

Avoiding Common Pitfalls

• Misdiagnosis leading to unnecessary interventions: Epiploic appendagitis is often misdiagnosed as appendicitis or diverticulitis, leading to unnecessary hospitalization, antibiotic use, and even surgery 1, 3
• Overtreatment: Recognition of the characteristic CT findings can prevent unnecessary surgical intervention 5
• Laboratory findings: Unlike appendicitis or diverticulitis, patients with epiploic appendagitis typically have normal white blood cell counts 4

Clinical Decision Algorithm

1. Confirm diagnosis of epiploic appendagitis on CT scan by identifying characteristic imaging findings 1, 3
2. Exclude other causes of acute abdominal pain that would require surgical intervention or hospitalization 5
3. Prescribe NSAIDs for pain control 2
4. Discharge patient with appropriate follow-up instructions 3
5. Consider surgical consultation only if symptoms are severe or persistent 2

By correctly identifying epiploic appendagitis on CT and understanding its benign, self-limiting nature, unnecessary hospitalization, antibiotic administration, and surgical interventions can be avoided, improving patient outcomes and reducing healthcare costs 1, 3.