Acute right lower quadrant (RLQ) pain is one of the commonest symptoms general surgeons are asked to evaluate. Apart from classical appendicitis, the differential diagnosis includes conditions confined to the appendix, such as cystadenoma or carcinoid, and those separate from the appendix, such as ruptured ovarian cyst, cecal diverticulitis, Crohn’s disease and other causes of terminal ileitis. Torsion of the epiploic appendix (appendagitis) can mimic appendicitis, but with new generation computed tomography (CT) scanners the 2 conditions can sometimes be differentiated preoperatively.
Case report
A 40-year-old woman presented to the emergency department with sudden onset of RLQ pain and nausea. On examination, her body temperature was 37.6°C and she complained of tenderness over McBurney’s point. Her leukocyte count was 14.2 × 109/L. CT was organized by the emergency physicians. The radiologist interpreted the scan (Fig. 1) as appendagitis. She was admitted for observation, and by the next day she was afebrile, her abdominal pain had resolved and her abdomen was nontender.
Contiguous axial images from a nonenhanced CT scan of the right lower quadrant. They show the mid-portion of a normal appendix being displaced medially by a well-circumscribed, oval shaped, fatty “mass.” The mass was attached to the lower portion of the ascending colon, which was not inflamed (not shown). In fact, the only inflammatory changes in the right lower quadrant were at the centre of the fatty “mass” (i.e., the epiploic appendage), as demonstrated by increased density. The base and tip of the appendix were normal (not shown).
Discussion
Primary epiploic appendagitis is a rare, benign, self-limiting, inflammatory process of the colonic epiploic appendices. 1 With the increased use of CT by the emergency department to investigate RLQ pain, this entity will be found more often by an experienced radiologist. Awareness of the CT appearance of acute appendagitis may help avoid an unnecessary operation since the management of this condition is expectant. All of the diagnostic experience of appendagitis on CT comes from investigation of left lower quadrant pain. However, there is no reason why this experience cannot be transferred to the interpretation of right-sided pain. Ultrasonography shows the characteristic finding of a hyperechoic mass localized under the point of maximum pain.2 CT typically shows a pericolic fatty mass with a greater attenuation than normal abdominal fat.3
Intraoperative management strategies are lacking in the literature, likely owing to the rarity of the condition, the avoidance of surgery in some cases that are suspected and the inability to diagnose it intraoperatively because of the minimal exposure available through a McBurney incision. Mazza and colleagues4 noted that with the increasing use of laparoscopy for appendicitis, the diagnosis of appendagitis is more likely to be made and can be treated with resection of the torted epiploic appendage.
Footnotes
Competing interests: None declared.
- Accepted March 29, 2005.