British Journal of Radiology (2004) 77, 707-708
© 2004 British Institute of Radiology
doi: 10.1259/bjr/25581195
Localized abdominal pain
K Bouzaïdi
C Ravard
and
M Levesque
Department of Radiology, Louis Mourier University Hospital, 178 Rue des Renouillers, Colombes 92700, France
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Introduction
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A 34-year-old man presented with a 24 h history of left lower abdominal quadrant pain. There were no signs of fever, nausea, vomiting or diarrhoea. Physical examination revealed localized tenderness without peritoneal irritation. There was a mild leucocytosis (12 x 109 l–1), and the erythrocyte sedimentation rate was 42 mm h–1. Ultrasound (Figure 1
) and spiral CT (Figures 2a, b) were performed. What is the diagnosis?
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Answer
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The ultrasound shows a slight hyperechoic, oval well circumscribed mass located below the abdominal wall, at the point of maximum tenderness. CT scan shows the oval-shaped mass bordered by a high attenuation peripheral rim, with fatty content. The surrounding fat is infiltrated and the bowel-wall is not thick. These appearances are characteristic of an infarcted epiploic appendage. The patient was treated conservatively and symptoms gradually resolved within 5 days.
Epiploic appendages are pedunculated, adipose structures protruding from the external surface of the colon into the peritoneal cavity [1, 2]. About 50 to 100 appendages are present normally and arranged in two separate longitudinal rows extending from the cecum to the rectosigmoid junction [3].
Primary epiploic appendagitis (PEA) is an acute abdominal condition due to spontaneous venous thrombosis or torsion with subsequent haemorrhagic infarction, fatty necrosis, inflammatory reaction and consequent peritoneal irritation [3–5]. Its incidence is underestimated. Currently, its diagnosis is made more often because of the liberal use of ultrasound and CT. The common site of PEA is the sigmoid colon, followed by the caecum. It most commonly occurs in adults [1].
The clinical presentation of the disease is non-specific [1, 4]; and it is consequently frequently misdiagnosed as either appendicitis, cholecystitis or diverticulitis, depending on its location. Symptoms consist of localized acute abdominal pain, which increases on deep inspiration and coughing, moderate fever and slight leukocytosis [3, 5]. A soft, non-distended abdomen with very localized tenderness is the usual finding [2]. Plain radiography can only suggest pathology of the epiploic appendages after healing saponification and calcification have occurred [5]. Calcified epiploic appendages can become detached from the mesentery and remain as a calcified intraperitoneal loose body showing an eggshell calcification [1, 3]. The ultrasound findings of PEA are quite characteristic. They include, at the spot of maximum tenderness, a small, oval, hyperechoic, non-compressible mass adherent to the colonic wall and fixed during deep breathing [3, 6]. A hypoechoic border is frequently noted and colonic wall changes are often absent [4, 5]. Doppler examination shows absence of signal in the hyperechoic mass secondary to ischaemia [4]. In contrast, increased vascularization often accompanies inflammatory processes (e.g. diverticulitis, apendicitis) [5]. The CT features are described as fatty attenuation paracolic lesion circumscribed by a characteristic hyperattenuating peripheral rim which represents the serosa covered with fibrinoleukocytic exudate [2, 5, 6]. Occasionally, there is a high-attenuating central dot corresponding with the thrombosed draining vein or necrosis [5], the neighbouring fatty tissue appears infiltrated.
Other than appendicitis, cholecystitis and diverticulitis, the differential diagnosis should include infarction of the omentum. In this entity, the hyperechoic mass is poorly defined, greater in size and localized medial to the colon, unlike PEA which is located laterally or anteriorly. Furthermore, infarction of the omentum does not have the hyperattenuating ring surrounding the lesion which is specific to PEA [3]. However, this distinction has no practical implications [1, 5].
PEA is a benign and self-limiting disease with spontaneous resolution. The treatment should consist of analgesics with complete resolution within 2 weeks [3].
In conclusion, the ultrasound and CT features of PEA are characteristic and may suggest the diagnosis, helping guide medical treatment and preventing unnecessary laparotomy.
Received for publication June 7, 2004.
Accepted for publication June 24, 2004.
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References
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