Primary epiploic appendagitis versus omental infarction : The role of MDCT

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1 Primary epiploic appendagitis versus omental infarction : The role of MDCT e-poster: EE-125 Congress: ESGAR 2010 Type: Educational Exhibit Topic: Diagnostic / Mesentery and Peritoneum Authors: P. Kraniotis, A. Kazantzi, E. Konstantatou, I. Tsota, A. Karatzas, MeSH: C. Kalogeropoulou; Patras/GR Omentum [A ] Colon [A ] Keywords: MDCT, Epiploic appendagitis, Omental infarction Any information contained in this pdf file is automatically generated from digital material submitted to e-poster by third parties in the form of scientific presentations. References to any names, marks, products, or services of third parties or hypertext links to third-party sites or information are provided solely as a convenience to you and do not in any way constitute or imply ESGAR s endorsement, sponsorship or recommendation of the third party, information, product, or service. ESGAR is not responsible for the content of these pages and does not make any representations regarding the content or accuracy of material in this file. As per copyright regulations, any unauthorised use of the material or parts thereof as well as commercial reproduction or multiple distribution by any traditional or electronically based reproduction/publication method is strictly prohibited. You agree to defend, indemnify, and hold ESGAR harmless from and against any and all claims, damages, costs, and expenses, including attorneys fees, arising from or related to your use of these pages. Please note: Links to movies, ppt slideshows and any other multimedia files are not available in the pdf version of presentations.

2 1. Learning Objectives Epiploic appendagitis as well as omental infarction are benign, self-limiting disease entities which can present with alarming symptoms, mimicking acute abdomen. Both are more frequently diagnosed now with the help of MDCT. Their prompt diagnosis is paramount in order to prevent unnecessary surgery. Epiploic appendagitis and omental infarction: Key facts Epiploic appendages are small fat-filled sacs situated near the lining of the colon, on the anti-mesenteric surface. They are between 0.5 and 5 cm long, each accompanied by one or two arterioles and a venule which is present in its vascular stalk attached to the colon. They may become acutely inflamed as a result of torsion (twisting) or venous thrombosis. This situation is now referred to as Epiploic Appendagitis(EA), which should not be confused with Acute Appendicitis. These entities are completely different and require different therapeutic approach, surgical or not. Usually, the average patient is about 35 to 40 years old male and develops acute abdominal pain, the location of which varies from left-sided, right, to central. The pain is stabbing and may be associated with nausea or vomiting. Fever is usually absent, as well as leukocytosis at the early stages. The differential diagnosis should include acute appendicitis, diverticulitis, cholecystitis, mesenteric lymphadenopathy, diverticulitis. 7.1% of patients investigated in order to exclude sigmoid diverticulitis have imaging findings of primary epiploic appendagitis, as epiploic appendages are more numerous and longer on the left colon. In these patients, most of the times a CT scan is performed in order to exclude surgical problems and EA is an incidental finding. EA follows a benign, self-limiting course and may be treated with antinflammatories and observation. The usual time course is about one week. A correct diagnosis is important to avoid unnecessary surgical or medical intervention. On CT, acute epiploic appendagitis has a more or less typical appearance in terms of location, size, and density. The most common finding on CT is a fat-density oval lesion with surrounding inflammation on the anterior aspect of the sigmoid colon. The changes on CT are not predictable in the 2-week to 6-month window. Whereas the location of acute epiploic appendagitis is most commonly adjacent to the sigmoid colon, acute omental infarction is typically located in the right lower quadrant and often is mistaken for acute appendicitis. With the broad use of Multi Detector Computed Tomography (MDCT), most patients with acute abdominal pain undergo CT scan evaluation. This is helpful as it provides a prompt diagnosis and therefore a more conservative approach for the patient. All patients should go under coagulation agents deficiency investigation if they don t have any risk factors to develop either epiploic appendagitis or omental infarction such as prior surgery in the area of the abdomen. 2. Background

3 We retrospectively reviewed 13 cases of patients, age range 14 to 65, who were diagnosed with either epiploic appendagitis or omental infarction, during the last 4 years. They presented with acute abdominal pain and (+) rebound with mild or absent fever, and mild leukocytosis. All patients were evaluated with standard abdominal CT with 16XMDCT and infusion of 120 ml of contrast at a flow rate of 3ml/sec. 3. Imaging Findings/Procedure Details Eleven cases depicted a characteristiacally inflamed epiploic appendage, i.e. a fatty density mass of oval shape on the antimesenteric surface of colon, with a centrally thrombosed vessel (figure groups 1 and 2). Two cases showed a larger omental inflammatory fatty mass compatible with omental infarct. (figure group 3) The fat surrounding the mass was of high density. Colon wall thickening did not always coexist. 4. Conclusion Epiploic appendagitis and omental infarction should always be considered in the acute abdomen differential diagnosis. MDCT on emergency basis helps to identify these entities and differentiate them from other common emergencies presenting with acute abdominal pain, such as appendicitis, diverticulitis etc MDCT with image reformation can show the typical appearance of both disese entities and help avoid unnecessary laparotomies. Epiploic appendages are small fat-filled sacs situated near the lining of the colon. They are between 0.5 and 5 cm long, each accompanied by one or two arterioles and a venule which is present in its vascular stalks attached to the colon. They may become acutely inflamed as a result of torsion (twisting) or venous thrombosis. This situation is now referred to as Epiploic Appendagitis, which should not be confused with Acute Appendicitis. These entities are completely different and require different therapeutic approach, surgical or not. Usually, the average patient is about 35 to 40 years old male and develops acute abdominal pain, the location of which varies from left-sided, right, to central. The pain is flank and stabbing and may be associated with nausea or vomiting. Fever is usually absent, as well as leukocytosis at the early stages. The differential diagnosis should include acute appendicitis, diverticulitis, cholecystitis, mesenteric lymphadenopathy, diverticulitis. 7.1% of patients investigated to exclude sigmoid diverticulitis have imaging findings of primary epiploic appendagitis. Most of the times a CT scan is conducted in order to exclude surgical problems and EA is an incidental finding. EA follows a benign, self-limiting course and may be treated with antinflammatories and observation. The usual time course is about one week. A correct diagnosis is important to avoid unnecessary surgical or medical intervention. On CT, acute epiploic appendagitis has a predictable appearance in terms of location, size, and density. The most common finding on CT is a fat-density oval lesion with surrounding inflammation on the anterior aspect of the sigmoid colon. The changes on CT are not predictable in the 2-week to 6-month window. Whereas the location of acute epiploic appendagitis is most commonly adjacent to the sigmoid colon, acute omental infarction is typically located in the right lower quadrant and often is mistaken for acute appendicitis. With the broad use of MDCT (Multi Detector Computed Tomography), most patients with acute

4 abdominal pain undergo CT scan evaluation as long as they have stable vital signs. This assessment is necessary because it provides a safer diagnosis and therefore a safer therapeutical approach for the patient. All patients should go under coagulation agents deficiency investigation as long as they don t have any risk factors to develop either epiploic appendagitis or omental infarction such as prior surgery in the area of the abdomen. Ct can distinguish these two entities but clinically the same but anticoag the infarct. 5. Author Information University Hospital of Patras Department of Radiology Computed Tomography Unit

5 6. Mediafiles

6 Left-sided epiploic appendagitis The inflamed apendage is located at the level of the junction between descending colon and sigmoid Figure 3 A left sided inflamed epiploic appendage

7 Figure 4 Coronal reconstruction of figure 3

8 Omental infaction Two different cases of omental infartion. The second at a lower level than the first. Figure 5 Larger than 5 cm fat density mass with inflammation signs and no colon involvement. The findings are consistent with the diagnosis of omental infarct.

9 Figure 6 Complicated omental infarct. No sign of colon involvement.

10 Right-sided epiploic appendagitis Figure 1 Adjacent to the ascending colon there is a fat density mass with a high density center (corresponding to the thrombosed vein) and is surrounded by the high attenuation rim which corresponds to the inflamed peritoneum. There is also fat stranding consistent with inflammation. Figure 2 Saggital reconstruction of figure 1: The inflamed epiploic appendage is better depicted on the sagittal plane.

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