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Special Feature
June 15, 2009

Image of the Month—Diagnosis

Arch Surg. 2009;144(6):587-588. doi:10.1001/archsurg.2009.62-b
Answer: Epiploic Appendagitis

After the dark mass was detached from the parietal peritoneum, a strangulated omental appendix became apparent and was constrained by 2 additional flanking appendices. After applying a loop to the neck of the appendix, it was removed. Pathological review of the specimen revealed fat necrosis and inflammatory cells within the omental appendix. The clinical course was uneventful, and the patient was discharged after 48 hours.

Omental appendices (also known as epiploic appendicesor epiploic appendages) are peritoneal pouches that arise from the serosal surface of the colon. Composed of adipose tissue and blood vessels, they have an average length of 3 cm. Those next to the sigmoid colon are the largest. The term epiploic appendagitiswas introduced in 1956 by Dockerty et al1to describe inflammation of these appendices. The main cause for inflammation and symptoms is torsion and/or strangulation of the appendages.2

On clinical examination, patients describe a localized strong, sharp pain. The abdominal pain is aggravated by movement but does not migrate. Most often, the patients have abdominal tenderness; otherwise, fever, vomiting, and leukocyte level elevation are absent. In general, the patient does not feel ill, has normal bowel movements, and has an adequately normal appetite. As in the case presented herein, sometimes the omental appendix twists temporally and causes intermittent pain. Historically, the diagnosis was made by laparotomy.3

Since the introduction of cross-sectional imaging, epiploic appendagitis can be diagnosed preoperatively. Computed tomographic features of epiploic appendagitis were first described in 1986 by Danielson et al.4The most common sites (in order of decreasing frequency) are adjacent to the sigmoid colon, the descending colon, and the ascending colon. The most common feature visible on CT is an oval lesion, ranging from 1.5 to less than 5 cm in diameter, with fat-equivalent attenuation abutting from the anterior colonic wall and perifocal fat stranding that represents inflammatory changes. Sometimes, central hyperdensity represents venous obstruction. Thickening of the adjacent peritoneal wall is also usually detected. In most cases, the wall of the colon appears unremarkable; in rare cases, wall thickening is seen.3

Therapy for appendagitis is still under debate. Because appendagitis is a self-limiting condition, some authors favor conservative treatment with administration of oral anti-inflammatory medication.3,5However, the literature describes a recurrence rate of up to 40%, and some of these patients require CT follow-up.6The value of minimally invasive surgery in the diagnosis and treatment of acute abdominal pain of unclear etiology is well known, and laparoscopic interventions are highly appealing to both the patient and surgeon. Furthermore, other abnormalities can be detected or excluded during laparoscopy. Therefore, we favor a laparoscopic approach whenever appendagitis is suspected.

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The Editor welcomes contributions to the Image of the Month. Manuscripts should be submitted via our online manuscript submission and review system (http://manuscripts.archsurg.com). Articles and photographs accepted will bear the contributor's name. Manuscript criteria and information are per the Instructions for Authors for Archives of Surgery(http://archsurg.ama-assn.org/misc/ifora.dtl). No abstract is needed, and the manuscript should be no more than 3 typewritten pages. There should be a brief introduction, 1 multiple-choice question with 4 possible answers, and the main text. No more than 2 photographs should be submitted. There is no charge for reproduction and printing of color illustrations.

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Article Information

Correspondence:Philipp Kirchhoff, MD, Department of Surgery, University of Basel, Spitalstrasse 21, 4031 Basel, Switzerland (kirchhoffp@uhbs.ch).

Accepted for Publication:November 10, 2008.

Author Contributions:Study concept and design: Viehl and Heizmann. Acquisition of data: Viehl. Analysis and interpretation of data: Kirchhoff, Oertli, and Potthast. Drafting of the manuscript: Kirchhoff, Viehl, and Potthast. Critical revision of the manuscript for important intellectual content: Heizmann and Oertli. Administrative, technical, and material support: Kirchhoff and Viehl. Study supervision: Viehl, Oertli, and Potthast.

Financial Disclosure:None reported.

References
1.
Dockerty  MBLynn  TEWaugh  JM A clinicopathologic study of the epiploic appendages. Surg Gynecol Obstet 1956;103 (4) 423- 433
PubMed
2.
Boulanger  BRBarnes  SBernard  AC Epiploic appendagitis: an emerging diagnosis for general surgeons. Am Surg 2002;68 (11) 1022- 1025
PubMed
3.
Singh  AKGervais  DAHahn  PFSagar  PMueller  PRNovelline  RA Acute epiploic appendagitis and its mimics. Radiographics 2005;25 (6) 1521- 1534
PubMed
4.
Danielson  KChernin  MMAmberg  JRGoff  SDurham  JR Epiploic appendicitis: CT characteristics. J Comput Assist Tomogr 1986;10 (1) 142- 143
PubMed
5.
Rao  PMMueller  PR Clinical and pathologic variants of appendiceal disease: CT features. AJR Am J Roentgenol 1998;170 (5) 1335- 1340
PubMed
6.
Sand  MGelos  MBechara  FG  et al.  Epiploic appendagitis—clinical characteristics of an uncommon surgical diagnosis [published online July 1, 2007]. BMC Surg 2007;711
PubMed10.1186/1471-2482-7-11
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