Primary Epiploic Appendagitis


Lincoln Medical and Mental Health Center, Bronx, New York


For the past 24 hours, a 15-year-old girl had localized abdominal pain (10 on a scale of 10) that was sharp and nonradiating. Her bowel movements had been normal. She was afebrile on presentation to the emergency department. She denied vomiting or diarrhea.

On examination, she had borderline tachycardia (heart rate, 95 beats per minute). Other vital signs were normal. She had tenderness and rebound of the right lower quadrant, with no rigidity or organomegaly, and normal bowel sounds.


Results of a urine pregnancy test were negative. A complete blood count showed leukocytosis (17,100 white blood cells/µL, with 78% neutrophils). A chemistry profile and urinalysis yielded normal results.

An abdominal computed tomography (CT) scan with oral and intravenous contrast showed a normal appendix, with stranding of retroperitoneal fat adjacent to the sigmoid colon and the proximal ileum representing epiploic appendagitis (Figure). The patient was admitted for conservative management with analgesics; within 2 days, her pain had resolved and she was discharged.

Primary epiploic appendagitis (PEA) is a rare disease characterized by inflammation of the epiploic appendages caused by spontaneous torsion or venous thrombosis of an appendage.1-4 In contrast, secondary epiploic appendagitis is caused by inflammatory or infectious processes in adjacent areas.

The incidence of PEA is low, especially in the pediatric population.5 Physical examination findings are nonspecific. The most common finding is localized tenderness in the right or left lower quadrant, with occasional rebound tenderness but no rigidity.3,5-7 Other associated symptoms include nausea, vomiting, high fever (temperature above 39°C [102.2°F]), and anorexia.5 Leukocytosis is another reported finding in PEA.5

The differential diagnosis of acute abdominal pain is vast and includes appendicitis, diverticulitis, cholecystitis, ovarian torsion, ectopic pregnancy, and mesenteric lymphadenitis. The radiologic differential diagnosis includes acute abdomen.8

Diagnosis most commonly is with ultrasonography or CT, with the latter being the preferred modality.9 In normal conditions, epiploic appendages are not visible on a CT scan. The characteristic CT finding is a small adipose mass (usually less than 5 cm) surrounded by a hyperdense rim adjacent to the colon.5

Almost all cases of PEA are putatively diagnosed as appendicitis or diverticulitis.5 In the past, the condition often had been misdiagnosed as acute abdomen, occasionally resulting in unnecessary surgery.6,7,10,11 With advances in radiology and established radiologic findings, PEA now is diagnosed more frequently.

Overall awareness of the entity still is low among surgeons.5 PEA is a self-limited disease that generally resolves spontaneously.12 Most patients recover with conservative management.6,9,12,13


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