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Torsion of an epiploic appendix mimicking acute appendicitis
International Journal of Surgery (2008) 6, 488e489
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Torsion of an epiploic appendix mimicking acute appendicitis Shams-ul-Bari*, Khurshid A. Sheikh, Ajaz A. Malik Department of General Surgery, Sher-i-Kashmir Institute of Medical Sciences (SKIMS), 190 006 Srinagar, Kashmir, India Available online 14 August 2006
Introduction Disorders of the epiploic appendages are rare.1,2 They usually affect the middle age group. They are rarely diagnosed pre-operatively and are commonly confused with diverticulitis of the sigmoid colon and other causes of acute abdomen. Conservative treatment with antibiotics and pain relief is usually safe. We present a case of a female patient with epiploic appendagitis being diagnosed pre-operatively as appendicitis.
Case report A 30-year-old woman presented to the Accident and Emergency Department of SKIMS with a history of pain in right lower abdomen since 1 day. The pain was continuous in nature. There was no history of vomiting, fever, and any change in bowel habit. There was history of decreased appetite and nausea. On examination she was well oriented with a pulse rate of 90/min and BP of 120/70mmHg. Chest and cardiovascular system were clinically normal. Abdomen was soft and non-distended. There was tenderness in the right iliac fossa with a positive rebound in the right iliac fossa. Bowel sounds and per rectum examination were normal. Laboratory investigations revealed Hb of 10.4 g%, total leukocyte count of 9300 with a differential count N76 L24. Kidney function tests and platelet count were normal. Urine examination showed 5e8 pus cells. Ultrasound
* Corresponding author. Tel.: þ91 194 2429203. E-mail address: [email protected] (Shams-ul-Bari).
abdomen was negative except for probe tenderness in right iliac fossa. In view of her history and physical examination, the patient was diagnosed as having acute appendicitis and was shifted to theatre for appendicectomy. At operation about 200 ml of serosanguinous fluid was found in the peritoneal cavity. Fluid could not be sent for any investigations. The sigmoid colon had migrated into the right iliac fossa because of a long mesentery. An appendix epiploica of sigmoid colon had undergone torsion and was gangrenous. The vermiform appendix was absolutely normal. The patient underwent an appendicectomy with excision of the gangrenous appendix epiploica of sigmoid colon. Initially a gridiron incision was given which was later converted into muscle cutting Rutherford incision so as to have a better exposure of the surrounding structures. We felt that the appendix should be removed at the same time as the patient could develop acute appendicitis in the future. The postoperative period was uneventful and the patient remained clinically normal and haemodynamically stable. She was discharged after 24 h. She tolerated orals well after 18 h of surgery and moved her bowels. The patient reported to our outpatient department several times and is now absolutely fine doing her routine job. Histology revealed a congested haemorrhagic and necrotic adipose tissue.
Discussion Epiploic appendages are pedunculated, fatty structures 2e5 cm in diameter scattered all over the colon and covered with peritoneum. They exist more on the left side. Epiploic appendagitis is more common in sigmoid colon as
1743-9191/$ - see front matter ª 2006 Surgical Associates Ltd. Published by Elsevier Ltd. All rights reserved. doi:10.1016/j.ijsu.2006.07.006
Torsion of an epiploic appendix compared to other parts of the colon. Clinical diagnosis is difficult, but with the routine use of CT scan, their preoperative diagnosis has become more common.3 They usually affect a middle age group.2 Necrosis of epiploic appendages is commonly due to an ischaemic event either secondary to torsion or spontaneous thrombosis.1 One can confuse the condition with diverticulitis of sigmoid colon but it can mimic acute appendicitis when it affects the caecum. Patients usually present with a sudden onset of sharp localized pain in the right iliac fosse or left iliac fossa, with minimal GIT symptoms. The temperature and white blood cell count can be normal or slightly elevated. Both USG and CT help in diagnosis. On USG, involved epiploicae will be seen as a hyperechoic non-compressible ovoid structure near the colonic wall. Doppler study demonstrates absence of blood flow. On CT, involved epiploicae will be seen as oval-shaped lesions 1.5e3.5 cm in diameter with attenuation similar to fat and with surrounding inflammatory changes that abut anterior sigmoid colonic walls. These characteristic findings on CT are diagnostic and allow safe conservative management in the majority of patients. Abdulzahavdom4 treated 52 patients with necrosis of epiploic appendices of the colon. Necrosis of epiploicae of appendix was seen in 4 patients, caecum in 7 patients, ascending colon in 5 patients, and descending colon in 7 patients. He justified surgical treatment of these patients. Horvath et al.5 reported 55 patients in the age group of 16 to 76 years with a diagnosis of epiploic appendagitis on the basis of clinical picture, and abdominal USG and CT. Fortyeight patients presented with pain in the left abdominal quadrant, 4 had pain in the right lower quadrant and 2
489 had epigastric pain. Abdominal USG and CT revealed inflammatory lesions of adipose origin, 1.5e5 cm in diameter. In all cases the mass subsided gradually with medical treatment. Hurreiz and Madaro6 reported a case of torsion of an epiploic appendix presenting as acute abdomen. The patient underwent appendicectomy with excision of the epiploic appendix.
Conclusion Acute epiploic appendagitis is a rare condition that can cause a diagnostic dilemma. Conservative treatment with analgesia and antibiotics is usually safe, but if diagnosis is made on exploration, treatment is ligation and excision of necrotic tissue with seromuscular inversion.
References 1. Pines B, Rabinovitch J, Biler SB. Primary torsion and infarction of appendices epiploicae. Arch Surg 1941;42:775e87. 2. Carmichael DH, Organ CH. Epiploic disorders. Conditions of epiploic appendages. Arch Surg 1985;120:1167e72. 3. Barbier C, Denny P, Pradoura JM, Bui P, Rieger A, Bazin C, et al. Radiologic aspects of infarction of the appendix epiploica. J Radiol 1998;79:1479e85. 4. Abdulzhavadom IM. Management of necrosis of epiploic appendices of colon. Khinurgiia (Mosk) 2006;2:44e6 [in Russian]. 5. Horvath E, Majlis S, Seguel S, Whittle C, Mackinnon J, Niedmann JP, et al. Primary epiploic appendigitis: Clinical and radiological diagnosis. Rev Med Chil 2000;128(6):601e7 [in Spanish]. 6. Hurreiz HS, Madavo CM. Torsion of epiploic appendix. Saudi Med J 2003;12(26):2005.
w w w. t h e i j s . c o m
Torsion of an epiploic appendix mimicking acute appendicitis Shams-ul-Bari*, Khurshid A. Sheikh, Ajaz A. Malik Department of General Surgery, Sher-i-Kashmir Institute of Medical Sciences (SKIMS), 190 006 Srinagar, Kashmir, India Available online 14 August 2006
Introduction Disorders of the epiploic appendages are rare.1,2 They usually affect the middle age group. They are rarely diagnosed pre-operatively and are commonly confused with diverticulitis of the sigmoid colon and other causes of acute abdomen. Conservative treatment with antibiotics and pain relief is usually safe. We present a case of a female patient with epiploic appendagitis being diagnosed pre-operatively as appendicitis.
Case report A 30-year-old woman presented to the Accident and Emergency Department of SKIMS with a history of pain in right lower abdomen since 1 day. The pain was continuous in nature. There was no history of vomiting, fever, and any change in bowel habit. There was history of decreased appetite and nausea. On examination she was well oriented with a pulse rate of 90/min and BP of 120/70mmHg. Chest and cardiovascular system were clinically normal. Abdomen was soft and non-distended. There was tenderness in the right iliac fossa with a positive rebound in the right iliac fossa. Bowel sounds and per rectum examination were normal. Laboratory investigations revealed Hb of 10.4 g%, total leukocyte count of 9300 with a differential count N76 L24. Kidney function tests and platelet count were normal. Urine examination showed 5e8 pus cells. Ultrasound
* Corresponding author. Tel.: þ91 194 2429203. E-mail address: [email protected] (Shams-ul-Bari).
abdomen was negative except for probe tenderness in right iliac fossa. In view of her history and physical examination, the patient was diagnosed as having acute appendicitis and was shifted to theatre for appendicectomy. At operation about 200 ml of serosanguinous fluid was found in the peritoneal cavity. Fluid could not be sent for any investigations. The sigmoid colon had migrated into the right iliac fossa because of a long mesentery. An appendix epiploica of sigmoid colon had undergone torsion and was gangrenous. The vermiform appendix was absolutely normal. The patient underwent an appendicectomy with excision of the gangrenous appendix epiploica of sigmoid colon. Initially a gridiron incision was given which was later converted into muscle cutting Rutherford incision so as to have a better exposure of the surrounding structures. We felt that the appendix should be removed at the same time as the patient could develop acute appendicitis in the future. The postoperative period was uneventful and the patient remained clinically normal and haemodynamically stable. She was discharged after 24 h. She tolerated orals well after 18 h of surgery and moved her bowels. The patient reported to our outpatient department several times and is now absolutely fine doing her routine job. Histology revealed a congested haemorrhagic and necrotic adipose tissue.
Discussion Epiploic appendages are pedunculated, fatty structures 2e5 cm in diameter scattered all over the colon and covered with peritoneum. They exist more on the left side. Epiploic appendagitis is more common in sigmoid colon as
1743-9191/$ - see front matter ª 2006 Surgical Associates Ltd. Published by Elsevier Ltd. All rights reserved. doi:10.1016/j.ijsu.2006.07.006
Torsion of an epiploic appendix compared to other parts of the colon. Clinical diagnosis is difficult, but with the routine use of CT scan, their preoperative diagnosis has become more common.3 They usually affect a middle age group.2 Necrosis of epiploic appendages is commonly due to an ischaemic event either secondary to torsion or spontaneous thrombosis.1 One can confuse the condition with diverticulitis of sigmoid colon but it can mimic acute appendicitis when it affects the caecum. Patients usually present with a sudden onset of sharp localized pain in the right iliac fosse or left iliac fossa, with minimal GIT symptoms. The temperature and white blood cell count can be normal or slightly elevated. Both USG and CT help in diagnosis. On USG, involved epiploicae will be seen as a hyperechoic non-compressible ovoid structure near the colonic wall. Doppler study demonstrates absence of blood flow. On CT, involved epiploicae will be seen as oval-shaped lesions 1.5e3.5 cm in diameter with attenuation similar to fat and with surrounding inflammatory changes that abut anterior sigmoid colonic walls. These characteristic findings on CT are diagnostic and allow safe conservative management in the majority of patients. Abdulzahavdom4 treated 52 patients with necrosis of epiploic appendices of the colon. Necrosis of epiploicae of appendix was seen in 4 patients, caecum in 7 patients, ascending colon in 5 patients, and descending colon in 7 patients. He justified surgical treatment of these patients. Horvath et al.5 reported 55 patients in the age group of 16 to 76 years with a diagnosis of epiploic appendagitis on the basis of clinical picture, and abdominal USG and CT. Fortyeight patients presented with pain in the left abdominal quadrant, 4 had pain in the right lower quadrant and 2
489 had epigastric pain. Abdominal USG and CT revealed inflammatory lesions of adipose origin, 1.5e5 cm in diameter. In all cases the mass subsided gradually with medical treatment. Hurreiz and Madaro6 reported a case of torsion of an epiploic appendix presenting as acute abdomen. The patient underwent appendicectomy with excision of the epiploic appendix.
Conclusion Acute epiploic appendagitis is a rare condition that can cause a diagnostic dilemma. Conservative treatment with analgesia and antibiotics is usually safe, but if diagnosis is made on exploration, treatment is ligation and excision of necrotic tissue with seromuscular inversion.
References 1. Pines B, Rabinovitch J, Biler SB. Primary torsion and infarction of appendices epiploicae. Arch Surg 1941;42:775e87. 2. Carmichael DH, Organ CH. Epiploic disorders. Conditions of epiploic appendages. Arch Surg 1985;120:1167e72. 3. Barbier C, Denny P, Pradoura JM, Bui P, Rieger A, Bazin C, et al. Radiologic aspects of infarction of the appendix epiploica. J Radiol 1998;79:1479e85. 4. Abdulzhavadom IM. Management of necrosis of epiploic appendices of colon. Khinurgiia (Mosk) 2006;2:44e6 [in Russian]. 5. Horvath E, Majlis S, Seguel S, Whittle C, Mackinnon J, Niedmann JP, et al. Primary epiploic appendigitis: Clinical and radiological diagnosis. Rev Med Chil 2000;128(6):601e7 [in Spanish]. 6. Hurreiz HS, Madavo CM. Torsion of epiploic appendix. Saudi Med J 2003;12(26):2005.