- Andres Gelrud, MD, MMSc
Andres Gelrud, MD, MMSc
- Associate Professor of Medicine
- University of Chicago
- Andrés Cárdenas, MD, MMSc, AGAF
Andrés Cárdenas, MD, MMSc, AGAF
- Institut de Malalties Digestives i Metaboliques
- Hospital Clinic, Barcelona, Spain
- University of Barcelona
- Sanjiv Chopra, MD, MACP
Sanjiv Chopra, MD, MACP
- Editor-in-Chief — Gastroenterology/Hepatology
- Section Editor — General Hepatology; Gallbladder and Biliary Tract Disease
- Professor of Medicine
- Harvard Medical School
- Senior Consultant in Hepatology
- James Tullis Firm Chief
- Beth Israel Deaconess Medical Center
Epiploic appendagitis, also known as appendicitis epiploica, hemorrhagic epiploitis, epiplopericolitis, or appendagitis, is a benign and self-limited condition of the epiploic appendages [1,2]. Inaccurate diagnosis can lead to unnecessary hospitalizations, antibiotic therapy, and surgical intervention [3-6]. This topic will review the clinical manifestations, diagnosis, and management of epiploic appendagitis.
Epiploic appendagitis is an ischemic infarction of an epiploic appendage caused by torsion or spontaneous thrombosis of the epiploic appendage central draining vein.
The true incidence of epiploic appendagitis is not known. However, epiploic appendagitis has been reported in 2 to 7 percent of patients who were initially suspected of having acute diverticulitis and in 0.3 to 1 percent of patients suspected of having acute appendicitis . Epiploic appendagitis occurs most commonly in the second to fifth decades of life with a mean age at diagnosis of 40 years. The incidence of epiploic appendagitis has been reported to be up to four times higher in men as compared with women [7-9]. Epiploic appendagitis can arise in any segment of the colon. In surgical case series, 57 percent of cases occur in the rectosigmoid, 26 percent in the ileocecum, 9 percent in the ascending colon, 6 percent in the transverse colon, and 2 percent in the descending colon [7,10,11]. Obesity and strenuous exercise may be risk factors for the development of epiploic appendagitis [7,11].
Epiploic appendages are small outpouchings of fat-filled, serosa-covered structures present on the external surface of the colon projecting into the peritoneal cavity. 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.
On average, the adult colon has approximately 50 to 100 appendages. Epiploic appendages occur all along the entire colon but are more abundant and larger in the transverse and sigmoid colon. They are usually rudimentary at the base of the appendix [1,12]. The appendages vary considerably in size, shape, and contour. Most epiploic appendages are 1 to 2 cm thick and 2 to 5 cm long, although they are occasionally up to 15 cm . For unclear reasons, they are largest and most prominent in obese persons and in those who have recently lost weight [1,14]. Although the exact role of epiploic appendages is not known, they are presumed to serve a protective and defensive mechanism similar to that offered by the greater omentum and may have a role in colonic absorption. They may also act as a cushion, protecting colonic blood supply during peristalsis .
- Pines BR, Beller J. Primary torsion and infarction of the appendices epiploicae. Arch Surg 1941; 42:775.
- DOCKERTY MB, LYNN TE, WAUGH JM. A clinicopathologic study of the epiploic appendages. Surg Gynecol Obstet 1956; 103:423.
- Mollà E, Ripollés T, Martínez MJ, et al. Primary epiploic appendagitis: US and CT findings. Eur Radiol 1998; 8:435.
- Rao PM, Rhea JT, Novelline RA, et al. Effect of computed tomography of the appendix on treatment of patients and use of hospital resources. N Engl J Med 1998; 338:141.
- Rao PM, Wittenberg J, Lawrason JN. Primary epiploic appendagitis: evolutionary changes in CT appearance. Radiology 1997; 204:713.
- Rao PM, Rhea JT, Wittenberg J, Warshaw AL. Misdiagnosis of primary epiploic appendagitis. Am J Surg 1998; 176:81.
- Schnedl WJ, Krause R, Tafeit E, et al. Insights into epiploic appendagitis. Nat Rev Gastroenterol Hepatol 2011; 8:45.
- Ozdemir S, Gulpinar K, Leventoglu S, et al. Torsion of the primary epiploic appendagitis: a case series and review of the literature. Am J Surg 2010; 199:453.
- Sand M, Gelos M, Bechara FG, et al. Epiploic appendagitis--clinical characteristics of an uncommon surgical diagnosis. BMC Surg 2007; 7:11.
- Macari M, Laks S, Hajdu C, Babb J. Caecal epiploic appendagitis: an unlikely occurrence. Clin Radiol 2008; 63:895.
- Rioux M, Langis P. Primary epiploic appendagitis: clinical, US, and CT findings in 14 cases. Radiology 1994; 191:523.
- Patterson DC. Appendices epiploicae and their surgical significance with report of three cases. N Engl J Med 1933; 209:1255.
- Linkenfeld F. Deutsche Ztschr f Chir 1908; 92:383.
- Ghahremani GG, White EM, Hoff FL, et al. Appendices epiploicae of the colon: radiologic and pathologic features. Radiographics 1992; 12:59.
- Sandrasegaran K, Maglinte DD, Rajesh A, Akisik FM. Primary epiploic appendagitis: CT diagnosis. Emerg Radiol 2004; 11:9.
- McGeer PL, McKenzie AD. Strangulation of the appendix epiploica: A series of 11 cases. Can J Surg 1960; 3:252.
- Shehan JJ, Organ C, Sullivan JF. Infarction of the appendices epiploicae. Am J Gastroenterol 1966; 46:469.
- Carmichael DH, Organ CH Jr. Epiploic disorders. Conditions of the epiploic appendages. Arch Surg 1985; 120:1167.
- Klingenstein P. Some phases of the pathology of the appendices epiploicae. Surg Gynecol Obstet 1924; 38:376.
- Horton KM, Corl FM, Fishman EK. CT evaluation of the colon: inflammatory disease. Radiographics 2000; 20:399.
- Rao PM. CT of diverticulitis and alternative conditions. Semin Ultrasound CT MR 1999; 20:86.
- Singh AK, Gervais DA, Hahn PF, et al. CT appearance of acute appendagitis. AJR Am J Roentgenol 2004; 183:1303.
- Deceuninck A, Danse E. Primary epiploic appendagitis: US and CT findings. JBR-BTR 2006; 89:225.
- Ng KS, Tan AG, Chen KK, et al. CT features of primary epiploic appendagitis. Eur J Radiol 2006; 59:284.
- Subramaniam R. Acute appendagitis: emergency presentation and computed tomographic appearances. Emerg Med J 2006; 23:e53.
- Sirvanci M, Balci NC, Karaman K, et al. Primary epiploic appendagitis: MRI findings. Magn Reson Imaging 2002; 20:137.
- Lee YC, Wang HP, Huang SP, et al. Gray-scale and color Doppler sonographic diagnosis of epiploic appendagitis. J Clin Ultrasound 2001; 29:197.
- van Breda Vriesman AC, Puylaert JB. Epiploic appendagitis and omental infarction: pitfalls and look-alikes. Abdom Imaging 2002; 27:20.
- Danse EM, Van Beers BE, Baudrez V, et al. Epiploic appendagitis: color Doppler sonographic findings. Eur Radiol 2001; 11:183.
- Görg C, Egbring J, Bert T. Contrast-enhanced ultrasound of epiploic appendagitis. Ultraschall Med 2009; 30:163.
- Desai HP, Tripodi J, Gold BM, Burakoff R. Infarction of an epiploic appendage. Review of the literature. J Clin Gastroenterol 1993; 16:323.
- Legome EL, Belton AL, Murray RE, et al. Epiploic appendagitis: the emergency department presentation. J Emerg Med 2002; 22:9.
- Legome EL, Sims C, Rao PM. Epiploic appendagitis: adding to the differential of acute abdominal pain. J Emerg Med 1999; 17:823.
- Vinson DR. Epiploic appendagitis: a new diagnosis for the emergency physician. Two case reports and a review. J Emerg Med 1999; 17:827.
- Sangha S, Soto JA, Becker JM, Farraye FA. Primary epiploic appendagitis: an underappreciated diagnosis. A case series and review of the literature. Dig Dis Sci 2004; 49:347.
- Patel VG, Rao A, Williams R, et al. Cecal epiploic appendagitis: a diagnostic and therapeutic dilemma. Am Surg 2007; 73:828.
- Puppala AR, Mustafa SG, Moorman RH, Howard CH. Small bowel obstruction due to disease of epiploic appendage. Am J Gastroenterol 1981; 75:382.
- Adler JE. Torsion of an appendix epiploica in a bilocular hernial sac. Lancet 1908; 172:377.
- ROSS JA, McQUEEN A. Peritoneal loose bodies. Br J Surg 1948; 35:313.
- CLINICAL MANIFESTATIONS
- Clinical presentation
- Laboratory findings
- Abdominal computed tomography scan
- Abdominal ultrasound
- DIFFERENTIAL DIAGNOSIS
- Conservative management
- NATURAL HISTORY AND DISEASE COURSE
- SUMMARY AND RECOMMENDATIONS