A case of epiploic appendagitis presenting with with acute pain in the left iliac fossa that started the day before. The objective of the case report is increasing knowledge of this disease and its diagnostic imaging findings, in order to reduce harmful and unnecessary surgical interventions.
A 45-year-old Caucasian man presented to our emergency department (ED) with acute pain in the left iliac fossa that started the day before presentation. At clinical examination VAS (visual analogue scale) score was 7/10. He had fever and nausea and denied any associated chills, trauma to the area, vomiting, dysuria, haematuria, change in bowel habits, loss of weight, or skin rash. He also denied any history of renal colic. His family history was positive for gallbladder diseases requiring cholecystectomy; surgical history was negative and no chronic diseases were reported. At physical examination the patient showed tenderness and pain in the left iliac fossa associated with abdominal guarding, suggestive for diverticulitis. There was no pulsatile or palpable mass or costovertebral angle tenderness. Physical examination was otherwise unremarkable. The patient was placed on observation status and laboratory and diagnostic tests were ordered. The patient was treated with an intravenous (IV) bolus of 250 mL of normal saline solution followed by 125 mL/h IV normal saline solution and Ketorolac trometamina (Toradol® Roche Pharmaceuticals, Switzerland) 30 mg IV for pain control. Laboratory results showed White Blood Cell (WBC) count of 12,10 x 1000/μl (4,8-10,8), with neutrophilia (87,3%) and fibrinogen of 839 mg/dL (160-350). Chest X-ray showed no lung consolidation, effusion, collapse, or air under the diaphragm. Abdominal X-ray was performed showing a poor representation of small and large bowel meteorism with no associated pathological air-fluid levels, as from spastic reflex ileus. An evaluation with abdominal US (Logiq e7™ GE Healthcare, USA) was performed using a high frequency linear probe (7,5 – 13Mhz) for the direct visualization of the descending and sigmoid colon in the left iliac fossa, because of the clinical suspicion of diverticulitis. US revealed a moderate reactive bowel wall thickening of the descending and the sigmoid colon with inflammatory change in the pericolonic fat, appearing as adjacent oval noncompressible hyperechoic mass, without internal vascularity and surrounded by a subtle hypoechoic line. According to the clinical conditions of the patient and the suggestive US findings, CT (128-slice Multidetector CT scanner GE Revolution GSI™, GE Healthcare, USA) scanning of the abdomen/pelvis with 120mL IV of iomeprol contrast media (Iomeron 400® Bracco, Italy) was also performed, confirming a moderate reactive wall thickening of the descending and the sigmoid colon with a nonenhancing adjacent fat-density ovoid structure characterized by a high-density rim and a surrounding inflammatory fat stranding. There was also CT evidence of colonic diverticulosis without CT evidence of diverticulitis. US and CT findings were most consistent with epiploic appendagitis. The patient remained under observation for 24 hours. Subsequently, upon symptoms improvement, the patient was discharged with a prescription for nonsteroidal anti-inflammatory medications and released into its family doctor’s care.