Epiploic appendagitis: An overlooked cause of acute abdominal pain

Abstract

Background: Epiploic appendagitis is a rare, often underrecognized cause of acute abdominal pain. Misdiagnosis can lead to unnecessary hospitalization, antibiotic use, or surgical intervention. Advances in imaging have improved the recognition of this self-limiting condition, but clinical awareness remains critical.

Aim: To provide a comprehensive update on the epidemiology, anatomy, pathogenesis, clinical presentation, diagnostic strategies, differential diagnosis, and management of epiploic appendagitis, emphasizing its distinguishing features from other causes of acute abdomen.

Methods: A review of the literature was conducted, focusing on the clinical characteristics, imaging findings, differential diagnoses, and evidence-based management strategies for epiploic appendagitis.

Results: Epiploic appendagitis typically presents with acute, localized, non-radiating abdominal pain without significant systemic symptoms. Diagnosis is heavily reliant on imaging, with computed tomography (CT) being the gold standard. Hallmark CT findings include a small, fat-density ovoid lesion adjacent to the colon, with the usual characteristic ring and dot signs. Differential diagnoses include mainly diverticulitis, appendicitis, omental infarction, and many other causes. Management is predominantly conservative with nonsteroidal anti-inflammatory drugs and observation, reserving surgical intervention for rare, complicated cases.

Conclusion: Recognizing the clinical and imaging features of epiploic appendagitis is essential to avoid unnecessary interventions. Increased clinician awareness, coupled with judicious use of imaging, facilitates timely diagnosis and appropriate management, ensuring optimal patient outcomes.

Keywords: Abdominal fat necrosis; Acute abdominal pain; Appendices epiploicae inflammation; Divericulitis; Epiploic appendagitis; Epiploic appendicitis.

Figure 1

Acute epiploic appendagitis in a 25-year-old man. Ultrasound evaluation of the area of maximum tenderness in the left iliac fossa shows a partially defined hyperechoic nodule with hypoechoic rim measuring about 1.5 cm × 0.7 cm. The surrounding fat appears hyperechoic.

Figure 2

Computed tomography-scan findings of acute epiploic appendagitis. A and B: In a 43-year-old woman: Axial (A); Coronal contrast-enhanced computed tomography-scan (B). Acute epiploic appendagitis in a 43-year-old man. A well-defined, oval-shaped fat density nodule is seen adherent to the anterior wall of the cecum, measuring 24 cm × 1.6 cm. It has a thick rim and is surrounded by mild fat stranding. This is in keeping with epiploic appendagitis; C and D: In a 35-year-old woman: Axial (C); Coronal contrast-enhanced computed tomography-scan (D). Acute epiploic appendagitis in a 35-year-old woman. An oval-shaped fat-density nodule is noted in the left lower abdomen abutting the anterior wall of the distal descending colon with mild surrounding fat stranding.

Figure 3

Diagnostic approach to localized lower abdominal pain suspected of epiploic appendagitis. GIT: Gastrointestinal tract; CBC: Complete blood count; CRP: C-reactive protein; B-HCG: Beta-human chorionic gonadotropin; US: Ultrasound; USKUB: Ultrasound of the kidneys, ureters and bladder; PID: Pelvic inflammatory disease; IBD: Inflammatory bowel disease; IBS: Irritable bowel syndrome.

Figure 4

Clinical management pathway for epiploic appendagitis. Conservative therapy is the mainstay in uncomplicated cases, while surgical intervention is reserved for patients with persistent symptoms or complications. CT: Computed tomography; NSAID: Nonsteroidal anti-inflammatory drug.