Epiploic Appendagitis

What Is It, Causes, Diagnosis, and More

Author:Lily Guo

Editors:Alyssa Haag,Ian Mannarino, MBA, MD

Illustrator:Jessica Reynolds, MS

Copyeditor:Sadia Zaman, MBBS, BSc

What is epiploic appendagitis?

Epiploic appendagitis refers to the inflammation and necrosis of the epiploic appendages, which are small, fat filled pouches that line the colon (i.e., large intestine). It most often occurs in those assigned male at birth, between the ages of 30 and 50 years of age. 

The epiploic appendages are approximately 1–2 cm thick and 0.5–5 cm long. Their role is not completely clear, however, they are thought to function as a blood reservoir, provide cushioning and immunity, and help in colonic absorption. They are pedunculated structures, which means they are attached to the surface of the colon by vascular stalks which contain veins and arteries. When the blood supply to these pouches is blocked, acute lower abdominal pain can result. 

Osmosis-style illustration of abdominal organs with zoom on epiploic appendagitis next to accurate CT image of appendagitis.

How rare is epiploic appendagitis?

While epiploic appendagitis is a relatively rare cause of acute lower abdominal pain, the exact incidence is currently unknown. Epiploic appendagitis has been reported in 2 to 7 percent of patients who were initially suspected of having acute diverticulitis and in 0.3 to 1 percent of patients initially suspected of having acute appendicitis

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What causes epiploic appendagitis?

Epiploic appendagitis is most commonly (up to 73% of cases) caused by torsion of the appendage, which leads to obstruction of the vascular supply and subsequent necrosis. Less common causes involve thrombosis or embolism of the vessels supplying the appendage, leading to ischemia. The appendages each contain small branches of the circular artery and a central draining vein. If there is torsion, an embolism, or a thrombosis that is causing blockage of the central draining vein, ischemic infarction and subsequent epiploic appendagitis can occur. While this can occur anywhere in the colon, it is more common in the sigmoid colon and transverse colon, as there are larger and more numerous epiploic appendages in these regions. Epiploic appendagitis is reported to be associated with obesity, hernia, and exercise injuries. 

What are the signs and symptoms of epiploic appendagitis?

Epiploic appendagitis presents as sudden, severe, and acute abdominal pain, most commonly in the left lower quadrant, that typically becomes aggravated from coughing and abdominal stretching. The abdomen may be tender to palpation and the pain may progressively worsen. The clinical features (e.g., onset, location, and severity of pain) can mimic those of acute diverticulitis and appendicitis. Other diagnoses with a similar presentation include pelvic inflammatory disease or a ruptured ovarian cyst. There are typically no other systemic symptoms or signs associated with epiploic appendagitis, and blood tests are usually within normal limits. For example, most people are afebrile and have a normal leukocyte (i.e., white blood cell) count. 

How is epiploic appendagitis diagnosed?

Epiploic appendagitis may be diagnosed by first ruling out other more emergent clinical diagnoses, such as appendicitis. The clinician may do a physical examination to evaluate the pain. The pain may worsen upon palpation of the abdomen, and there is typically rebound tenderness, where there is more pain upon removal of pressure when compared to the pain experienced upon initial palpation to the abdomen. Very rarely, people experience nausea and vomiting. 

The clinician may also perform laboratory testing to rule out infectious causes. Since epiploic appendagitis does not have very specific clinical features, it is typically diagnosed with computerized tomography (CT) imaging. The classic CT findings include an ovoid shaped lesion with fat density, mild bowel wall thickening, and central high-attenuation focus (i.e., a bright dot) within the fatty lesion. 

How is epiploic appendagitis treated?

Epiploic appendagitis is a benign and self-limiting condition. Analgesics, such as nonsteroidal anti-inflammatory (NSAID) medications, can be administered to relieve the pain. Unlike appendicitis or diverticulitis, it typically does not require hospitalization, antibiotics, or surgical intervention. The individual may see a gastroenterology clinician for continuity of care, and they may perform colonoscopies to monitor the condition. In cases where the epiploic appendagitis is diagnosed during operative exploration (i.e., laparoscopy), the treatment is usually ligation and excision of the lesion. 

How serious is epiploic appendagitis?

Epiploic appendagitis can be considered non-serious since it does not require hospitalization or antibiotics, and is typically not life-threatening. While it may cause severe pain, the condition is self-limiting and should resolve on its own over time. Once the epiploic appendage is cut off from its blood supply, the fatty pouch typically calcifies and the pedicle, or stalk connecting the appendage to the colon, atrophies. Finally, the appendage detaches from the colon and becomes a peritoneal loose body, which does not cause symptoms. 

What are the most important facts to know about epiploic appendagitis?

Epiploic appendagitis is a rare cause of pain in the lower abdomen, usually on the left side. It occurs due to ischemia of the epiploic appendages located on the surface of the colon. Ischemia is most commonly due to torsion, which cuts off blood flow, However, thrombosis and embolism can also be causes. The symptoms of epiploic appendagitis can frequently be mistaken for acute appendicitis and diverticulitis, especially considering it is a more rare condition. Accurate diagnosis typically requires CT scan and treatment consists of NSAIDs to reduce pain. Since it is self limiting, hospitalization is not usually required. 

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Related links

Appendicitis: Pathology review
Diverticular disease: Pathology review

Resources for research and reference

Giambelluca, D., Cannella, R., Caruana, G., Salvaggio, L., Grassedonio, E., Galia, M., Midiri, M., & Salvaggio, G. (2019). CT imaging findings of epiploic appendagitis: an unusual cause of abdominal pain. Insights into Imaging, 10(1), 26. DOI: 10.1186/s13244-019-0715-9

Malik K. A. (2010). Torsion of an epiploic appendix pretending as acute appendicitis. Oman Medical Journal, 25(3), 225–226. DOI: 10.5001/omj.2010.62

Subramaniam, R. (2006). Acute appendagitis: emergency presentation and computed tomographic appearances. Emergency medicine journal, 23(10), e53. DOI: 10.1136/emj.2005.033704

Suresh Kumar, V. C., Mani, K. K., Alwakkaa, H., & Shina, J. (2019). Epiploic Appendagitis: An Often Misdiagnosed Cause of Acute Abdomen. Case reports in gastroenterology, 13(3), 364–368. DOI: 10.1159/000502683