|LETTER TO THE EDITOR
|Year : 2013 | Volume
| Issue : 4 | Page : 257-258
Epiploic appendagitis: An uncommon cause of acute abdomen
Pankaj Kumar Garg1, Rajiv Verma1, Bhupendra Kumar Jain1, Seema Aggarwal2
1 Department of Surgery, University College of Medical Sciences and Guru Teg Bahadur Hospital, University of Delhi, Delhi, India
2 Department of Pathology, University College of Medical Sciences and Guru Teg Bahadur Hospital, University of Delhi, Delhi, India
|Date of Web Publication||4-Dec-2013|
Pankaj Kumar Garg
Department of Surgery, University College of Medical Sciences and Guru Teg Bahadur Hospital, Delhi 110 095
Source of Support: None, Conflict of Interest: None
|How to cite this article:|
Garg PK, Verma R, Jain BK, Aggarwal S. Epiploic appendagitis: An uncommon cause of acute abdomen
. Ann Afr Med 2013;12:257-8
An 18-year-old young man, resident of North India, presented to the surgical emergency room with complaints of noncolicky pain in the right iliac fossa for 2 days in duration which was sudden in onset, severe in intensity, localized in the right lower side of the abdomen. The patient did not have any other bowel or urinary complaints. The medical history was unremarkable. The physical examination revealed tachycardia (pulse rate of 108/min) with marked tenderness at McBurney's point. The rest of the abdominal examination was unremarkable. His total leucocyte count was 11800/mm 3 , with 90% neutrophils in differential count. A clinical diagnosis of acute appendicitis was made. Ultrasound scan of abdomen did not reveal any significant finding. In view of strong clinical suspicion of acute appendicitis, the patient was undertaken for appendicectomy through a grid iron incision. During exploration, an inflamed epiploic appendage was found attached to redundant sigmoid colon which migrated to the right iliac fossa. The inflamed epiploic appendage was lying juxtaposed to the noninflammed appendix vermiformis. The inflamed epiploic appendage was ligated and excised. Appendicectomy was also accomplished. The postoperative course was uncomplicated and the patient was discharged from the hospital on the 2 nd postoperative day. Histopathological examination of excised tissue specimen showed inflamed appendices epiploicae with congested blood vessels and inflammatory infiltrate [Figure 1]. Histopathological examination of excised appendicectomy specimen showed normal vermiform appendix.
|Figure 1: (H and E, × 200): Inflamed appendices epiploicae (arrow: Peritoneal surface) with congested blood vessels and inflammatory infiltrate (inset)|
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Acute inflammatory conditions of epiploic appendages are rarely in the differential diagnosis of acute abdomen due to low incidence of this condition and unawareness on the part of junior surgeons. Epiploic appendices (appendices epiploicae) are small (0.5-5.0 cm long) pouches of peritoneum, around 100 in number from the cecum to the sigmoid colon, protruding from the external serosal surface. They are present on the antimesenteric border of the colon.  Appendices epiploicae were first described by Vesalius in 1543 and first identified on computed tomography (CT) scan in 1986.  Each appendage has one or two small arteries and one vein.
The causes of acute appendagitis include spontaneous torsion and hemorrhagic infarct, calcification due to aseptic fat necrosis, primary or secondary inflammation, enlargement by lipomas or metastasis, and incarceration in hernias. , Acute appendagitis may mimic acute appendicitis clinically if it involves the right colon or a redundant sigmoid colon migrating to the right side.  There may be associated complaints of nausea and vomiting. Patient may be febrile with an elevated leucocyte count.
Epiploic appendagitis is rarely diagnosed preoperatively due to lack of pathognomic clinical findings and unavailability of expert radiological modalities in emergency settings in developing countries where health resources are scarce Ultrasound and CT scans are good diagnostic modalities. In a retrospective analysis of 20 patients of epiploic appendagitis, Hasbahceci et al.,  showed that a solid oval, noncompressible hyperechoic mass with a subtle hypoechoic rim directly under the site of maximal tenderness, and lack of central blood flow on Doppler US (detected in five of six patients) is suggestive of epiploic appendagitis. They also showed that a pericolonic ovoid fatty mass with hyperattenuating rim and surrounding fat stranding is a diagnostic finding, which was present in all 20 patients of epiploic appendagitis.
Conservative management of with antibiotics, analgesics with supportive care is all that is required for the management of acute epiploic appendagitis if definitive preoperative diagnosis is established; otherwise, ligation and excision of the necrotic tissue should be done if found during operation.
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