Introduction: Acute epiploic appendagitis (EA) is a self-limited inflammation of the appendices epiploicae. Epiploic, also known as omental, appendages are pouches that derive from the peritoneum. These appendages are made of adipose tissue and each appendage contains a venous and arterial supply. If torsion of the appendage occurs, occlusion of the vascular supply can lead to ischemia and may cause EA. Acute EA is associated with obesity, abdominal hernias, and heavy or unaccustomed exercise. EA management is supportive. The increased utilization of CT imaging for acute abdomen visits to emergency rooms nationwide has led to increased identification of this condition. Such radiographic diagnosis has obviated the need for unproven therapies such as antibiotics and surgery.
Case Description/Methods: A 66-year-old male with past medical history of gastrointestinal stromal tumor status post small bowel resection presented to the emergency room complaining of epigastric abdominal pain of one day duration. The pain was constant, non-radiating, cramping, and awakened him from sleep. The patient rated the pain as 7/10 in intensity. The pain was not alleviated by acetaminophen use and was associated with three loose, non-bloody, non-mucoid bowel movements. A CT of the abdomen/pelvis showed an ovoid fat density area adjacent to the descending colon with a high-density rim and mild surrounding inflammatory fat stranding, suggestive of EA. He was treated with oral anti-inflammatory medications and discharged home. At follow-up one week later his abdominal pain had completely resolved.
Discussion: This case illustrates that EA is not commonly considered in the differential for abdominal pain. Fortunately, this condition is easily diagnosed on CT imaging. With the rise of CT scan use in the work-up of acute abdominal pain, EA is easily identified and can be appropriately managed. Radiographically, acute EA is described as an oval-shaped mass lesion of fat density with a hyper-attenuating dense rim. EA is a self-limited and self-resolving condition. The treatment is oral anti-inflammatory medication with recovery expected within ten days. There is no indication for antibiotics in acute EA. Correct diagnosis is meaningful to avoid unnecessary hospital stay. The importance in highlighting this case is that EA diagnosis is very unlikely in the absence of CT scanning due to lack of clinician awareness and uncommon nature of the disease. This case highlights the radiologic assessment of EA and its appropriate treatment.
