Epiploic appendagitis: an overlooked entity by clinicians

A 41-year-old woman was referred to our Department for persistent lower left-sided abdominal pain. Two weeks before she complained of diarrhea of two-day duration. Immediately afterwards she began experiencing an increasingly sharp and severe abdominal pain in the left lower quadrant for which she twice visited the Emergency Department; however no definite diagnosis was established and irritable bowel syndrome was suspected. Physical examination showed localized pain with tenderness in the left lower quadrant. Laboratory testing revealed an increased C-reactive protein (CRP) level to 9.4 mg/L (normal <5 mg/L). Both gynecological examination and colonoscopy were unremarkable. A multi-slice contrastenhanced computed tomography (CT) of the abdomen was performed which showed a lesion on the left side of the abdominal cavity, adjacent to sigmoid colon, characterized by fat density centrally and mesenteric fat stranding in the periphery (Fig. 1). The CT findings were compatible with primary epiploic appendagitis and the patient was treated with analgesics and antibiotics leading to gradual resolution of symptoms. Primary epiploic appendagitis (PEA) is the inflammation process of the epiploic appendage, composed of fat and blood vessels, protruding from the serosal surface of the colon. The clinical picture of PEA includes acute onset of abdominal pain with left or right lower quadrant tenderness. Some patients report fever, vomiting, diarrhea or nausea. Laboratory findings, including white blood cell count and CRP, are usually normal or slightly elevated. CT findings of PEA are specific and characteristic as described in our case. The treatment is non-surgical with antibiotics and analgesics. Figure 1 CT showing hypodense lesion anterior to sigmoid colon, with adjacent mesenteric fat stranding (arrow). a