What is the recommended treatment for epiploic appendagitis in an otherwise healthy adult with acute localized abdominal pain and no systemic signs of infection?

Treatment of Epiploic Appendagitis

Conservative management with NSAIDs and observation is the definitive treatment for epiploic appendagitis, with symptoms typically resolving within a few days to one week without antibiotics or surgery. 1, 2, 3

Immediate Management

• Initiate oral NSAIDs (such as ibuprofen 400-600 mg every 6-8 hours or naproxen 500 mg twice daily) as the primary therapeutic intervention for pain control and anti-inflammatory effect 1, 4, 3
• Reassure the patient that this is a self-limited condition that does not require antibiotics or surgical intervention in the vast majority of cases 1, 2, 5
• Avoid antibiotics entirely—they provide no benefit since epiploic appendagitis is an ischemic/inflammatory process, not an infectious one 1, 2, 5

Diagnostic Confirmation

• CT abdomen/pelvis with IV contrast is the gold standard for diagnosis, showing characteristic findings: (1) oval fat-density lesion with hyperattenuating ring sign, (2) mild adjacent bowel wall thickening, and (3) central high-attenuation dot sign within the fatty lesion 2, 5
• The diagnosis must be confirmed by imaging to distinguish epiploic appendagitis from acute diverticulitis or appendicitis, which require different management 1, 2, 4

Outpatient Management Protocol

• Discharge home with oral NSAIDs once the diagnosis is confirmed by CT imaging 1, 4
• Schedule follow-up within 5-7 days to confirm symptom resolution 1, 3
• Provide return precautions: instruct the patient to return immediately if pain worsens, fever develops, or new symptoms such as vomiting or peritoneal signs appear 4, 3

Expected Clinical Course

• Pain typically resolves within 3-7 days with conservative management alone 1, 2, 3
• Most patients experience significant improvement within 48-72 hours of starting NSAIDs 4, 5
• Complete resolution occurs spontaneously even without treatment in many cases, though NSAIDs accelerate symptom relief 1, 4

Surgical Intervention (Rare)

• Reserve surgery only for: (1) persistent symptoms beyond 7-10 days despite adequate NSAID therapy, (2) development of complications such as bowel obstruction or abscess formation, or (3) diagnostic uncertainty when imaging is equivocal and symptoms worsen 1, 4
• Laparoscopic excision of the affected epiploic appendage is the preferred surgical approach when intervention is required 4
• Surgical intervention is needed in fewer than 10% of cases 1, 4

Common Pitfalls to Avoid

• Do not prescribe antibiotics—this is a sterile inflammatory process, and antibiotics expose patients to unnecessary side effects and costs without benefit 1, 2, 5
• Do not admit to hospital unless complications develop or the diagnosis remains uncertain after imaging 1, 2, 4
• Do not proceed to surgery based on clinical suspicion alone without CT confirmation, as this leads to unnecessary operations for a self-limited condition 2, 4, 3
• Do not mistake this for appendicitis or diverticulitis—the key distinguishing features are: absence of fever, minimal or absent leukocytosis, localized sharp pain without systemic symptoms, and characteristic CT findings 2, 4, 5

Clinical Presentation Clues

• Typical patient: middle-aged (average age 40-45 years), male predominance, often obese 4, 3, 5
• Pain location: left lower quadrant (80% of cases) or right lower quadrant (20% of cases), sharp and localized 4, 5
• Absent systemic features: no fever, no nausea/vomiting, no diarrhea, normal or minimally elevated WBC and CRP 4, 3, 5
• This constellation of localized pain without systemic illness should immediately raise suspicion for epiploic appendagitis rather than infectious causes 4, 5