Diagnostic Ultrasound - Abdomen and Pelvis

Epiploic Appendagitis
Diagnoses: Bowel
Pelvic Inflammatory Disease
• Usually occurs in women of childbearing age
• Bilateral tubo-ovarian masses
• May have reactive inflammation to perienteric and
pericolonic fat
• Usually presents with systemic symptoms
• Associated with presence of intrauterine contraceptive
device
PATHOLOGY
General Features
• Etiology
○ Torsion of epiploic appendage along its long axis with
impairment of its vascular supply and subsequent venous
thrombosis
○ Spontaneous central vein thrombosis resulting in
necrosis (also possible)
Gross Pathologic & Surgical Features
• Acute infarction with inflammation, fat necrosis, vessel
thrombosis, and hemorrhagic suffusion
• Torsion is seldom seen intraoperatively
CLINICAL ISSUES
Presentation
• Most common signs/symptoms
○ Abrupt onset of very localized abdominal pain, most
frequently left lower quadrant, gradually resolving over
3-10 days
○ Palpable mass (10-30%)
○ Obesity and strenuous exercise are recognized risk
factors
• Other signs/symptoms
○ Mild or absent systemic symptoms and signs
• Clinical profile
○ White cell count may be normal or mildly elevated
Demographics
• Age
○ 4th-5th decades of life
• Gender
○ Male predominance (M:F = 4:1)
• Epidemiology
○ True incidence is unknown but is less than < 1%
Natural History & Prognosis
• Prognosis
○ Usually self-limiting condition with clinical recovery
within 10 days
○ CT findings may persist beyond 6 months
– Calcified mobile "stone" in dependent peritoneal
recesses may persist long-term
• Complications are rare but may include
○ Abscess formation
○ Adhesions
○ Bowel obstruction
○ Intussusception
○ Peritonitis
Treatment
• Conservative management with oral anti-inflammatory
medication
• Antibiotics are not routinely indicated
DIAGNOSTIC CHECKLIST
Image Interpretation Pearls
• Noncompressible avascular hyperechoic oval mass,
adjacent to colon, deep to region of maximal tenderness
• Normal or mild localized asymmetric thickening of adjacent
colonic wall
• Peripheral 2-3 mm hypoechoic/hyperattenuating rim of
inflamed visceral peritoneum
• Central focus of hypoechogenicity/hyperattenuation
(central engorged or thrombosed vessel &/or central areas
of hemorrhage)
SELECTED REFERENCES
1. Menozzi G et al: Contrast-enhanced ultrasound appearance of primary
epiploic appendagitis. J Ultrasound. 17(1):75-6, 2014
2. Oztunali C et al: Radiologic findings of epiploic appendagitis. Med Ultrason.
15(1):71-2, 2013
3. Kamaya A et al: Imaging manifestations of abdominal fat necrosis and its
mimics. Radiographics. 31(7):2021-34, 2011
4. Sand M et al: Epiploic appendagitis--clinical characteristics of an uncommon
surgical diagnosis. BMC Surg. 7:11, 2007
5. Singh AK et al: CT appearance of acute appendagitis. AJR Am J Roentgenol.
183(5):1303-7, 2004
6. Boardman J et al: Radiologic-pathologic conference of Keller Army
Community Hospital at West Point, the United States Military Academy:
torsion of the epiploic appendage. AJR Am J Roentgenol. 180(3):748, 2003
7. Rioux M et al: Primary epiploic appendagitis: clinical, US, and CT findings in 14
cases. Radiology. 191(2):523-6, 1994
8. Carmichael DH et al: Epiploic disorders. Conditions of the epiploic
appendages. Arch Surg. 120(10):1167-72, 1985
9. Thomas JH et al: Epiploic appendagitis. Surg Gynecol Obstet. 138(1):23-5,
1974
10. Fieber SS et al: Appendices epiploicae: clinical and pathological
considerations; report of three cases and statistical analysis on one hundred
five cases. AMA Arch Surg. 66(3):329-38, 1953
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