HJ Kim

Abstract

Epiploic appendagitis is a rare non-specific disease that can be confused with other diseases. Herein, we report a case of epiploic appendagitis with chronic abdominal pain in a 15-year-old boy with a body mass index of 31 kg/m², who visited our emergency room with a complaint of acute-onset abdominal pain and intermittent fever. Examination of the abdomen revealed tenderness and rebound tenderness in the right lower quadrant (RLQ). Computed tomography (CT) imaging demonstrated a 2.2-cm low attenuating lesion abutting the ascending colon with pericolic fat stranding. Because of the persistent RLQ pain and tenderness, follow-up CT was performed and it showed a decreased lesion without complications. This indicates that epiploic appendagitis may be associated with chronic pain, although this association is very rare.

Introduction

Epiploic appendages are fat-filled, small pedunculated structures that are present along the colon wall and are accompanied by one or two arterioles and a venule.^1,2 Spontaneous venous thrombosis of an appendage-draining vein or torsion of the epiploic appendages can cause inflammation, and acute abdominal pain is a major symptom of epiploic appendagitis.³ Mild fever may be present in some patients; however, other symptoms such as nausea, vomiting, and diarrhoea are rare. These symptoms usually resolve within 2 weeks.¹ Obesity and heavy exercise are risk factors for the development of epiploic appendagitis.^4,5 This report describes a case of epiploic appendagitis with chronic abdominal pain in a 15-year-old obese boy.

Case Report

A 15-year-old boy who had been previously diagnosed with irritable bowel syndrome (diarrhoea type) visited the emergency room complaining of acute-onset abdominal pain lasting for 1 day, which remained localised in the right lower quadrant (RLQ). He had intermittent fever and watery diarrhoea. The body mass index (BMI) of the patient was 31 kg/m². Examination of the abdomen showed tenderness and rebound tenderness in the RLQ. Laboratory study findings were unremarkable, except for increased alanine aminotransferase. Because of RLQ tenderness, a computed tomography (CT) scan was obtained, which demonstrated a 2.2-cm low attenuating lesion abutting the ascending colon with pericolic fat stranding and diffuse fatty infiltration in the liver without focal lesions (Figure 1A). The patient was managed conservatively with oral anti-inflammatory medication. On the third day in the outpatient clinic, the fever and watery diarrhoea were resolved; however, RLQ abdominal pain and tenderness persisted for 2 months. Abdominal pain did not disturb social life. A follow-up CT performed 2 months after diagnosis demonstrated a slightly decreased lesion, but a 1.7-cm low attenuating lesion abutting the ascending colon was still noted (Figure 1B). A few days later, the abdominal pain was resolved.

Discussion

Epiploic appendages are peritoneal pouches that are present in the serosal surface of the colon. The length of these appendages range from 0.5 to 5 cm and they consist of adipose tissue and blood vessels. Ischaemia due to torsion or venous occlusion is the main cause of acute epiploic appendagitis.^1-3

Previous studies have reported an association between obesity, unaccustomed exercise, and epiploic appendagitis.^4,5 Our patient with a BMI of 31 kg/m² had also non-alcoholic fatty liver disease as a complication of obesity. In addition to this being a rare disease, it is noteworthy also because obese patient had chronic clinical symptoms.

Epiploic appendagitis can occur at any age. However, it occurs most commonly in the 4th to 5th decades of life, and predominantly in men. The sigmoid colon and the caecum are the predominant sites of occurrence.⁶

The clinical signs and symptoms of epiploic appendagitis are non-specific. Thus, it is difficult to diagnose and is often confused with other diseases based on its occurrence site. It can mimic acute appendicitis, if the right side of the body is involved. Moreover, it may mimic diverticulitis or acute cholecystitis when it occurs in the sigmoid colon or proximal part of the transverse colon.^7-9

Occasionally, an unnecessary procedure may have been performed. Rashid et al⁷ presented a 7-year-old boy misdiagnosed preoperatively with acute appendicitis and subsequently, during surgical exploration, was found to have caecal appendagitis. In the present case, it was first thought that the patient had appendicitis, but the diagnosis was changed based on CT findings; experienced radiologists can help clinicians in this regard. The most common CT finding is an oval lesion less than 5 cm in diameter that has an attenuation equivalent to that of fat, which abuts the anterior colonic wall, and is surrounded by inflammatory changes. Another finding is the thickening of the parietal peritoneum secondary to the spread of inflammation.⁶

These CT findings can persist for 6 months after diagnosis, but clinical signs and symptoms may be self-limiting within 2 weeks in most cases.¹⁰ However, our case had clinical symptoms that persisted for 2 months. Therefore, a follow-up CT was performed to find complications or other lesions, but without success. Persistent abdominal pain without any complications may occur.

In conclusion, this report details the first case of epiploic appendagitis with chronic pain. This condition can be confused with other diseases and knowledge of CT features is especially important in obese patients.

Declaration of Interest

Author reports no conflicts of interest.

Figure 1 CT image showing a 2.2-cm low attenuating lesion abutting the ascending colon with pericolic fat stranding (A) slightly decreased, however, a 1.7-cm low attenuating lesion can be observed abutting the ascending colon with improved pericolic fat stranding (B).

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