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1 Department of Surgery, Keller Army Community Hospital, West Point, NY
10996-1197.
2 Department of Pathology, Walter Reed Army Medical Center, 7100 Georgia Ave.
N.W., Washington, DC 20307-5001.
3 Department of Radiology, Keller Army Community Hospital, West Point, NY
10996-1197.
4 Department of Radiology, Wake Forest University School of Medicine, Medical
Center Blvd., Winston-Salem, NC 27157-1088.
Received April 24, 2002;
accepted after revision May 30, 2002.
The opinions and assertions contained herein are those of the authors and
should not be construed as official or as representing the opinions of the
Department of the Army or the Department of Defense.
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The patient's symptoms did not improve with medical therapy. Diagnostic laparoscopy revealed an inflammatory mass adherent to the bowel wall of the descending colon. The mass was excised. Final pathologic diagnosis was necrotic appendix epiploica with surrounding hemorrhage (Fig. 1B).
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Epiploic appendixes are small (0.5-5.0 cm long) pouches of peritoneum filled with fat and small vessels that protrude from the serosal surface of the colon. They occur in the rectosigmoid junction (57%), ileocecal region (26%), ascending colon (9%), transverse colon (6%), and descending colon (2%) [1]. Occasionally they are found on the appendix or small bowel.
Possible complications associated with epiploic appendages include inflammation or torsion (73%), intrahernial content (18%), obstruction (8%), intraperitoneal loose bodies, and low colonic intussusception [1]. Epiploic appendagitis, denoting inflammation of an epiploic appendix from any cause, may be primary or secondary. Primary epiploic appendagitis is caused by torsion or spontaneous venous thrombosis of the involved epiploic appendage. Secondary epiploic appendagitis is associated with inflammation of adjacent organs, such as diverticulitis, appendicitis, or cholecystitis. Primary epiploic appendagitis occurs in the second to fifth decades of life without sexual predominance. Patients may present with localized abdominal pain of variable intensity and duration, rebound tenderness, an abdominal mass, mild fever, and mild leukocytosis. The nonspecific symptoms may mimic appendicitis, diverticulitis, omental infarction, pelvic inflammatory disease, or a ruptured ovarian cyst. Until the advent of sonography and CT, primary epiploic appendagitis was rarely diagnosed correctly before surgery.
On sonography, primary epiploic appendagitis appears as a solid, hyperechoic, noncompressible ovoid mass surrounded by a subtle hypoechoic line [2]. Mass effect on the adjacent bowel wall and anterior parietal peritoneum is seen in 71% and 93% of cases, respectively. On CT, the lesion appears as a fatty mass that is connected to the serosal surface of the colon and has slightly higher attenuation than does peritoneal fat. All masses have a hyperattenuating peripheral rim on CT, corresponding to the hypoechoic line seen on sonography, that represents swelling of the serosa covered with fibrinoleukocytic exudate. All masses have periappendiceal fat stranding, and a few may have a central dot of high attenuation, possibly caused by a thrombosed vessel in the epiploic appendix or by the apposing surfaces of two adjacent appendixes [2, 3].
Before the advent of cross-sectional imaging, treatment of primary epiploic appendagitis was simple excision. Recently, patients diagnosed on CT as having primary epiploic appendagitis have been treated conservatively [3].
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