British Journal of Radiology 74 (2001),1062-1064 © 2001 The British Institute of Radiology
Strangulated small bowel obstruction related to chronic torsion of an epiploic appendix: CT findings
A Osadchy, MD,
M Shapiro-Feinberg, MD and
R Zissin, MD
Department of Diagnostic Imaging, Meir Hospital, Sapir Medical Center, Kfar-Saba, affiliated to the Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
Correspondence: Dr A Osadchy, Department of Diagnostic Imaging, Sapir Medical Center, Kfar Saba, 44281, Israel
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Abstract
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The role of CT in the evaluation of patients with small bowel obstruction, with emphasis on the findings of strangulating obstruction, has been extensively described in the literature. We report a rare case of small bowel volvulus related to a heterogeneous abdominal mass detected on CT. On microscopic examination the mass proved to be a chronically torted epiploic appendix.
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Introduction
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CT now plays an important role in the evaluation and management of patients with small bowel obstruction (SBO), establishing the correct diagnosis, defining a possible aetiology and eliciting signs of strangulation requiring surgical intervention [1–4]. A high diagnostic accuracy of abdominal CT in differentiating simple and strangulated SBO has been recently reported [2–4], leading to increasing use of this modality in the appropriate clinical setting. We have encountered a case of SBO as the result of volvulus of a bowel segment around a mass proved to be a torted epiploic appendix (EA). Torsion of an EA is an infrequent condition with confusing clinical symptoms and its diagnosis can easily be overlooked [5–7].
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Case report
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An 86-year-old man was admitted with a 1-day history of gradually worsening vomiting and epigastric pain. A nasogastric tube was inserted and 3 L of coffee ground fluid were drained. His medical history included diabetes mellitus and no previous abdominal operations. Physical examination showed diffuse abdominal tenderness with decreased peristalsis. Laboratory tests were unremarkable. Plain abdominal radiographs showed dilatation of small bowel loops with air–fluid levels, compatible with SBO. Abdominal CT following both oral and iv contrast medium was then performed. Dilated, thick-walled small bowel loops with a radial distribution converging towards a 5 x 5 cm2 mass consisting of soft tissue, fat and peripheral calcified foci in the right lower quadrant were seen on CT. Mesenteric vascular engorgement, mesenteric haziness and fluid, and a small amount of peritoneal fluid were also demonstrated (Figures 1a–c
). These findings were interpreted as strangulated SBO related to an indeterminate mass. At surgery, bloody peritoneal fluid and a closed loop of strangulated and ischaemic terminal ileum were found. An adherent band coursing from the mesenteric border of the affected small bowel to an egg-sized tumour acted as an axis for the small bowel volvulus. This band was released and the gangrenous bowel loop and tumour were then resected. Histology of the surgical specimen showed ischaemic bowel and a calcified infarcted EA. The post-operative course was uneventful.
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Figure 1. (a) Contrast enhanced CT at mid abdomen level shows distended small bowel loops, contrast-filled loops without mural thickening, and fluid-filled, thick-walled loops, with engorged mesenteric vessels (black arrowheads) indicating volvulus. Note the collapsed small bowel loops in the right abdomen, distal to the strangulating obstruction (white arrow). (b) At the pelvis, dilated, thick-walled small bowel loops with a radial distribution converge towards a mass in the right lower quadrant (arrow). Note the mesenteric haziness. (c) Image 1.5 cm caudal to (b) shows the complexity of the mass (white arrow), consisting of soft tissue, fat (black arrowhead) and peripheral calcified flecks.
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Discussion
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The EAs have no known function. They are more common on the transverse and pelvic colon, being rarely found on the vermiform appendix and on the small bowel. EAs vary considerably in size, shape and contour in various parts of the colon, with an average length of 3 cm, the longest being in the sigmoid colon. Their blood supply is derived from the superior and inferior mesenteric arteries, with venous drainage into the corresponding veins and occasionally the renal veins [6].
The most common complications of EA are inflammation and torsion, either acute or chronic. With torsion, the EA twists on its long axis, leading to venous obstruction and oedema, with further vascular impairment causing infarction and gangrene. Acute torsion usually presents with localized symptoms and signs of peritonitis in the lower quadrants of the abdomen, including guarding and rebound tenderness [5, 7]. Chronic torsion usually goes unrecognized clinically and produces saponification, with calcification of the fatty organ leading to the formation of a mass [6]. When the mass is large enough it can be palpated or may be detected on CT as a heterogeneous mass, as was the case in our patient. Infrequently, the long-standing infarction may cause amputation of the EA, which may then appear as a loose calcified peritoneal body [8]. As evidenced by the paucity of reported cases, torsion of an EA is a rare condition with a confusing clinical presentation. The diagnosis may therefore be delayed or missed [5–7]. Our case is very unusual, not only for the rarity of this entity but also for the resulting SBO, which has not been reported previously in relation to EA torsion. A case with similar CT findings of small bowel volvulus, but connected to a calcified mesenteric lymph node, has recently been reported [9].
As CT is often performed for various acute and chronic abdominal conditions, the radiologist should be aware of the possibility of this rare entity of chronic torsion and necrosis of the EA, which may be first recognized on CT as a heterogeneous mass containing fat and calcium.
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Acknowledgments
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We gratefully acknowledge Prof. M Hertz for her assistance in the preparation of this manuscript.
Received for publication February 16, 2001.
Revision received May 10, 2001.
Accepted for publication May 15, 2001.
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References
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Abstract
Introduction
