What is the management of epiglottic appendagitis?

Epiploic Appendagitis: Clinical Significance and Management

Epiploic appendagitis is a benign, self-limiting inflammatory condition that should be managed conservatively with NSAIDs, avoiding unnecessary antibiotics, hospitalization, and surgery. 1, 2

Clinical Significance

Epiploic appendagitis represents a rare but important cause of acute abdominal pain that is frequently misdiagnosed as more serious conditions requiring surgical intervention. 1, 3

Key clinical features include:

• Focal lower quadrant abdominal pain (most commonly left-sided, though right-sided presentations occur) without systemic symptoms 3
• Absence of fever, nausea, vomiting, or changes in bowel habits in most cases 3
• Normal or minimally elevated inflammatory markers (unlike appendicitis or diverticulitis) 3
• Highest incidence in middle-aged obese males 3

Why Recognition Matters

The primary significance of correctly diagnosing epiploic appendagitis lies in preventing unnecessary interventions. When misdiagnosed as appendicitis or diverticulitis, patients may undergo:

• Unwarranted surgical procedures 4
• Inappropriate antibiotic therapy 2
• Unnecessary hospital admissions 4
• Dietary restrictions and extended workups 4

Diagnostic Approach

CT imaging is the diagnostic modality of choice and reveals characteristic findings that allow confident diagnosis. 1, 2

CT findings include:

• Oval lesion with central fat attenuation 4
• Surrounding inflammatory changes 4
• Typically 1-4 cm in size, located adjacent to the colon 1

Ultrasound can be used in pediatric and obstetric populations where radiation exposure should be minimized, though CT remains superior for definitive diagnosis. 4

Management Protocol

Conservative Management (First-Line)

NSAIDs are the primary treatment for symptomatic relief, with most cases resolving within days to one week. 1, 3, 5

Specific approach:

• Outpatient management is appropriate for most patients 1
• NSAIDs (e.g., lornoxicam 8 mg or equivalent) for pain control 5
• No antibiotics required as this is not an infectious process 2
• Symptoms typically resolve within a few days with or without treatment 1

When to Consider Surgery

Surgical intervention is reserved only for:

• Persistent symptoms despite conservative management 3
• Development of complications (rare) 3
• Diagnostic uncertainty when imaging is inconclusive 1

Common Pitfalls to Avoid

Do not mistake epiploic appendagitis for:

• Acute appendicitis (right-sided presentations) - epiploic appendagitis lacks fever, leukocytosis, and progressive symptoms 3
• Acute diverticulitis (left-sided presentations) - epiploic appendagitis has minimal systemic inflammatory response 5
• Cholecystitis (when located in right upper quadrant) 4

Critical distinction: Unlike appendicitis or diverticulitis, epiploic appendagitis presents with localized pain but minimal systemic signs and normal or near-normal laboratory values. 3

Clinical Algorithm

1. Patient presents with focal abdominal pain (typically lower quadrant)
2. Assess for systemic signs: fever, tachycardia, elevated WBC
3. If systemic signs absent and pain localized → obtain CT imaging 2
4. CT confirms epiploic appendagitis → initiate outpatient NSAID therapy 1, 5
5. Reassess in 3-5 days - expect symptom resolution 1
6. If symptoms persist beyond 1 week → consider surgical consultation 3

The key to optimal management is accurate imaging diagnosis, which transforms a potential surgical emergency into a simple outpatient condition requiring only symptomatic treatment. 4