Epiploic appendagitis

Official reprint from UpToDate®
Epiploic appendagitis
Author
Andres Gelrud, MD
Andrés Cárdenas, MD, MMSc
Sanjiv Chopra, MD
(結腸附件炎、腸脂垂炎)
Section Editor
Lawrence S Friedman, MD
Deputy Editor
Peter A L Bonis, MD
Last literature review for version 16.3: 十月 1, 2008 | This topic last updated: 三月 15,
2007
INTRODUCTION — Epiploic appendagitis (EA), also known as appendicitis epiploica, hemorrhagic
epiploitis, epiplopericolitis, or appendagitis, is a benign and self-limited condition of the epiploic
appendages that occurs secondary to torsion or spontaneous venous thrombosis of a draining vein
[1,2]. EA occurs most commonly in the second to fifth decades of life; the mean age in several reports
was approximately 38 years and there was a similar incidence among men and women. Complete
resolution without surgical intervention usually occurs between 3 to 14 days [3-6]. Inaccurate
diagnosis can lead to unnecessary hospitalizations, antibiotic therapy, and surgical intervention [7].
ANATOMY — Epiploic appendages are small outpouchings of fat-filled, serosa-covered structures
present on the external surface of the colon projecting into the peritoneal cavity. The appendages are
situated along the entire colon and are more abundant and larger in the transverse and sigmoid
colon. Approximately 50 to 100 appendages are present in the colon of an average person. They are
usually rudimentary at the base of the appendix [1,8].
The epiploic appendages vary considerably in size, shape, and contour. For unclear reasons, they are
largest and most prominent in obese persons and in those who have recently lost weight [1,9]. The
average length of the epiploic appendage is 3 cm, although they are occasionally up to 15 cm [10].
They are presumed to serve a protective and defensive mechanism similar to that offered by the
greater omentum. They may also act as a protective cushion during peristalsis [1].
Each appendage encloses small branches of the circular artery and vein that supply the corresponding
segment of the colon. Subserosal lymphatic channels either terminate in a lymph node within an
appendage or loop through its base en route to mesenteric nodes. (具有動靜脈及淋巴管)
PATHOPHYSIOLOGY — Epiploic appendagitis is usually caused by torsion, which occurs when the
appendage is abnormally long and large. The vein, which is longer than the artery by virtue of its
tortuous course, alters the anatomy such that the pedicle is predisposed to twisting. Spontaneous
venous thrombosis of a draining vein can also predispose to twisting of the appendage pedicle.
Gradual torsion of the appendages can result in chronic inflammation with minimal or no symptoms.
In contrast, acute strangulation is associated with the development of symptoms. Symptomatic EA
can arise on any segment of the colon. The affected site was in the sigmoid colon or cecum in 75
percent of 156 patients in a retrospective study [2].
There are other less common conditions affecting the epiploic appendices. They can slide into a
femoral, umbilical, or inguinal hernia sac where they may remain without causing symptoms or (less
commonly) incarcerate with or without torsion [8,11]. The appendices can also calcify, cast off, and
lie free as foreign bodies (corpora aliena) in the peritoneal cavity or become surrounded by omental
adhesions [12]. Epiploic appendages are thought to represent the most frequent source of
intraperitoneal loose bodies, which are usually found in the pelvis [13]. These may become
secondarily attached elsewhere in the abdomen and can be confused with a neoplastic process.
CLINICAL MANIFESTATIONS — Patients most commonly present with acute abdominal pain.
Symptoms can mimic an acute abdomen, frequently leading patients to be misdiagnosed as having
acute appendicitis or diverticulitis.
On physical examination patients usually do not appear to be seriously ill and are afebrile. There is
localized pain in the affected area, more often in the left lower than right lower quadrant. Rebound
tenderness is usually not present [14]. A mass is palpable in 10 to 30 percent of patients [15]. The
remainder of the examination is usually unremarkable.
Laboratory tests are useful for excluding other causes of similar symptoms. There are no
pathognomonic diagnostic laboratory findings. The white blood count with differential and erythrocyte
sedimentation rate are normal or only moderately elevated [4,16].
DIAGNOSIS — EA should be considered in the differential diagnosis of patients presenting with
localized lower abdominal pain without associated leukocytosis or fever (show table) [12,17,18]. EA
has been reported in 2 to 7 percent of patients in which a clinical suspicion of diverticulitis was
entertained and in 0.3 to 1 percent of patients suspected of having appendicitis [17,19,20]. The
diagnosis should also be considered when exploration of the abdomen fails to reveal any of the more
common causes an acute abdomen.
Early radiologic examination with an abdominal CT scan is key in making the diagnosis. This was
illustrated in a retrospective study of 19 cases of EA presenting over a four-year period in which a
diagnosis was made by abdominal CT scan [6]. Prior to having the abdominal CT scan performed,
two-thirds of patients were suspected of having either appendicitis or diverticulitis.
CT findings are virtually pathognomonic for EA while excluding other causes of abdominal pain. The
appendices epiploica are usually not seen on CT scan unless they are surrounded by a sufficient
amount of intraperitoneal fluid such as ascites or hemoperitoneum. The classic finding is a 2 to 3 cm,
oval-shaped, fat density, paracolic mass with thickened peritoneal lining and periappendageal fat
stranding [4,18,21-25]. A high-attenuated central dot within the inflamed appendage that
corresponds to a thrombosed draining appendageal vein is occasionally evident [4,20]. MRI findings of
EA have not been well studied but appear to correlate with CT findings [26].
EA can also be diagnosed on abdominal ultrasonography in both gray-scale and color Doppler, an
approach probably best suited for patients with a thin body habitus seen at centers with experience in
sonographic imaging of the colon. The inflamed appendage appears as a non-compressible, solid,
hyperechoic ovoid mass with a subtle hypoechoic rim located at the point of maximal tenderness [4].
The inflamed fatty mass is fixed to the colon and often also to the parietal peritoneum during
inspiration and expiration. Doppler studies typically reveal absence of blood flow in the appendage
[5,23,27,28]. (See "Transabdominal ultrasonography of the small and large intestine").
TREATMENT — EA is a benign and self-limiting condition in which the abdominal CT scan appearance
can lead to a confident diagnosis. Patients can be managed conservatively with oral anti-inflammatory
medications and occasionally a short course of opiates [3,4,6,29,30]. Anti-inflammatories provide
analgesia but probably do not modify the disease. Although there are no strict guidelines for therapy,
we suggest ibuprofen (600 mg po every eight hours for four to six days) and Tylenol #3
(acetaminophen/codeine 300/30) every six hours as needed for four to six days. Most patients
respond to these measures in about four to seven days. Patients should be advised to seek medical
attention if symptoms worsen after two days (such as with the development of high fever, progressive
pain, nausea, vomiting, or inability to tolerate an oral diet). As a general rule, patients do not require
hospitalization or antibiotics.
Complications are uncommon. Inflamed appendages can adhere to the abdominal wall or other
viscera predisposing to intestinal obstruction and intussusception [31]. Inflamed and necrotic
appendages can also rarely progress to abscess formation for which surgery is usually indicated. The
risk of recurrence has not been described but is probably very low.
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REFERENCES
1.
Pines, BR, Beller, J. Primary torsion and infarction of the appendices epiploicae. Arch Surg
1941; 42:775.
2.
DOCKERTY, MB, LYNN, TE, WAUGH, JM. A clinicopathologic study of the epiploic
appendages. Surg Gynecol Obstet 1956; 103:423.
3.
Desai, HP, Tripodi, J, Gold, BM, Burakoff, R. Infarction of an epiploic appendage. Review of
the literature. J Clin Gastroenterol 1993; 16:323.
4.
Rioux, M, Langis, P. Primary EA: Clinical, US, and CT findings in 14 cases. Radiology 1994;
191:523.
5.
Lee, YC, Wang, HP, Huang, SP, et al. Gray-scale and color Doppler sonographic diagnosis of
epiploic appendagitis. J Clin Ultrasound 2001; 29:197.
6.
Legome, EL, Belton, AL, Murray, RE, et al. Epiploic appendagitis: the emergency
department presentation. J Emerg Med 2002; 22:9.
7.
Rao, PM, Rhea, JT, Wittenberg, J, Warshaw, AL. Misdiagnosis of primary EA. Am J Surg
1998; 176:81.
8.
Patterson, DC. Appendices epiploicae and their surgical significance with report of three
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9.
Ghahremani, GG, White, EM, Hoff, FL, et al. Appendices epiploicae of the colon: Radiologic
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10.
Linkenfeld, F. Deutsche Ztschr f Chir 1908; 92:383.
11.
Adler, JE. Torsion of an appendix epiploica in a bilocular hernial sac. Lancet 1908; p.377.
12.
Klingenstein, P. Some phases of the pathology of the appendices epiploicae. Surg Gynecol
Obstet 1924; 38:376.
13.
Ross, J, McQueen, A. Peritoneal loose bodies. Brit J Surg 1948; 35:313.
14.
McGeer, PL, McKenzie, AD.Strangulation of the appendix epiploica: A series of 11 cases.
Can J Surg 1960; 3:252.
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Gastroenterol 1966; 46:469.
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Carmichael, DH, Organ, CH Jr. Epiploic disorders. Conditions of the epiploic appendages.
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19.
Rao, PM, Rhea, JT, Novelline, RA, et al. Effect of computed tomography of the appendix on
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20.
Rao, PM, Wittenberg, J, Lawrason, JN. Primary EA: Evolutionary changes in CT appearance.
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Rao, PM. CT of diverticulitis and alternative conditions. Semin Ultrasound CT MR 1999;
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Singh, AK, Gervais, DA, Hahn, PF, et al. CT appearance of acute appendagitis. AJR Am J
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Subramaniam, R. Acute appendagitis: emergency presentation and computed tomographic
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Sirvanci, M, Balci, NC, Karaman, K, et al. Primary epiploic appendagitis: MRI findings. Magn
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van Breda Vriesman, AC, Puylaert, JB. Epiploic appendagitis and omental infarction: Pitfalls
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GRAPHICS
Differential diagnosis in patients with epiploic appendagitis
Appendicitis
Left- or right-sided diverticulitis
Gallbladder disease
Ruptured or hemorrhagic ovarian cyst
Ovarian torsion
Ectopic pregnancy
Segmental omental infarction
Colon cancer or metastasis
Abscess
Mesenteric adenitis
Crohn's ileitis
Urachal cyst
Ileitis caused by infection with Yersinia, Campylobacter or Salmonella
Mesenteric panniculitis
CT Appearance of Acute Appendagitis
實際CT範例說明
Fig. 1.—41-year-old
old man with left lower quadrant
pain from acute epiploic appendagitis.Axial
Axial
contrast-enhanced CT scan shows fat-density
density lesion
with surrounding hyperdense rim and inflammation
(arrow)) abutting the distal descending colon.
Fig. 2.—32-year-old
old man with right upper abdominal
pain from acute epiploic appendagitis. Contrastenhanced
hanced CT scan shows 6-cm-long
6
inflamed
epiploic appendagitis with surrounding inflammation
(arrowheads)) abutting ascending colon and right
anterior abdominal wall musculature
Fig. 3.—47-year-old
old man with left lower quadrant
pain due to acute epiploic appendagitis. Contrastenhanced CT scan shows fat-density
density lesion with
central focal hyperdensity and surrounding
inflammation (arrowhead) abutting sigmoid
colon–descending colon junction.
Fig. 4.—61-year-old
old man with left lower quadrant
pain from acute epiploic appendagitis. ContrastContrast
enhanced CT scan shows central hyperdense focus
(arrowhead)) within inflamed appendix epiploica
anterior to sigmoid colon.
Fig. 5.—52-year-old
old woman with left lower quadrant
pain from acute epiploic appendagitis. ContrastContrast
enhanced CT scan shows fat-density
density lesion (arrow)
(
with surrounding inflammation abutting sigmoid colon
and anterior abdominal wall musculature.
musculature
Fig. 6.—64-year-old
old woman with right flank pain from
acute appendagitis. Contrast--enhanced CT scan
shows fat-density lesion (arrow)
arrow) with surrounding
inflammation in ascending mesocolon.
mesocolo
以上六張圖來自 American
merican journal of Roentgenology ( AJR 2004; 183:1303-1307
183:1303
)
Pathognomonic CT scan findings are a 2–4 cm, oval shaped, fat density lesion,
surrounded by inflammatory changes. One can distinguish a central focal area of
hyper-attenuation with surrounding inflammation. Thickening of the parietal
peritoneum wall can be sometimes observed. In contrast to diverticulitis the
diameter of the colonic wall is mostly regular without signs of thickening.
以上兩張圖來自 BMC Surgery (BMC Surgery 2007, 7:11)
Made by zeno 2008.12.15