What is epiploic appendagitis?

Understanding Epiploic Appendagitis

Epiploic appendagitis is a rare, self-limiting inflammatory condition of the fat-filled serosal outpouchings (epiploic appendices) attached to the colon that typically causes acute abdominal pain but resolves on its own with conservative management.

What Are Epiploic Appendices?

• Epiploic appendices are small (1.5-3.5 cm) fat-filled pouches that protrude from the outer surface of the colon, primarily along the cecum and sigmoid colon 1
• These structures are covered by peritoneum and have their own blood supply and venous drainage 2

Types and Causes

• Primary epiploic appendagitis (PEA): Occurs when an epiploic appendage undergoes torsion (twisting), leading to:
  • Ischemia (restricted blood flow)
  • Thrombosis (blood clot formation) in the draining vein 1
• Secondary epiploic appendagitis: Develops in association with other inflammatory conditions of the abdomen, most commonly diverticulitis 1

Symptoms

• Sharp, localized abdominal pain that typically comes on suddenly 2, 3
• Pain most commonly occurs in the left lower quadrant (80%) or right lower quadrant (20%) 4
• Unlike many other causes of abdominal pain, epiploic appendagitis typically presents with:
  • No fever
  • No nausea or vomiting
  • Normal or only slightly elevated inflammatory markers (like C-reactive protein) 4

How It's Diagnosed

• Computed tomography (CT) is the diagnostic test of choice 1
• Classic CT findings include:
  • An oval-shaped fatty mass measuring between 1.5-3.5 cm
  • A hyperattenuating (hyperdense) ring surrounding the mass
  • A central hyperdense dot or area (representing thrombosed vessels)
  • Inflammation in the surrounding fat tissue 5, 1
• These findings are often described as the "hyperattenuating ring sign" and "central dot sign" 5
• Ultrasound and MRI can also identify epiploic appendagitis, which is important in pediatric and pregnant patients where radiation exposure is a concern 2

Why It's Important to Recognize

• Epiploic appendagitis is a clinical mimicker of more serious conditions that require surgical intervention, including:
  • Appendicitis
  • Diverticulitis
  • Omental infarction
  • Gynecological conditions 2, 1
• Correct diagnosis prevents:
  • Unnecessary hospital admissions
  • Inappropriate antibiotic use
  • Dietary restrictions
  • Unnecessary surgical procedures 2

Treatment

• Conservative management is the standard of care, including:
  • Pain control with analgesics
  • Non-steroidal anti-inflammatory drugs (NSAIDs) 3
• Surgical intervention is rarely needed 4
• The condition is self-limiting and typically resolves within a few days to weeks 1

Important Considerations

• Awareness of this condition among healthcare providers is crucial to avoid misdiagnosis 4
• With increased use of CT scans for evaluating acute abdominal pain, epiploic appendagitis is being diagnosed more frequently 4
• In patients with localized, sharp abdominal pain without other symptoms (fever, nausea, vomiting) or laboratory abnormalities, epiploic appendagitis should be considered in the differential diagnosis 4