Curled appendix mimics epiploic appendagitis

Posted By Wael Nemattalla
Curled appendix mimics epiploic appendagitis

28 years old female with right iliac fossa pain and suspected acite appendicitis. CT revealed right adnexal pathology and normal curled appendix that mimics ring sign of epiploic appendagitis.

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  • Wael Nemattalla 2013-12-21 20:25:39

    Epiploic appendagitis

    Epiploic appendagitis is a rare self limiting inflammatory / ischaemic process involving an appendix epiploica of the colon, and may either be primary or secondary to adjacent pathology. This article pertains to primary (spontaneous) epiploic appendagitis.


    This condition usually affects patients in their 2nd to 5th decades with a predilection for women and obese individuals, presumably due to larger appendices 6.

    Clinical presentation

    Clinically patients present with abdominal pain and guarding. It is essentially indistinguishable from diverticulitis and acute appendicitis (depending on location) and although an uncommon condition, it accounts for up to 7% of cases of suspecteddiverticulitis 1. Since there is focal peritoneal irritation, pain maybe more localized than in the other causes of acute abdominal pain.


    Epiploic appendagitis merely denotes inflammation of the one or more appendices epiploicae, which number 50-100 and are distributed along the large bowel with variable frequency 3-4,6:

    • rectosigmoid junction - 57%

    • ileocecal region - 26%

    • ascending colon - 9%

    • transverse colon - 6%

    • descending colon - 2%

    The pathogenesis is thought to be due to torsion of a large and pedunculated appendix epiploicae, or spontaneous thrombosis of the venous outflow, resulting in ischaemia and necrosis 3.

    Radiographic features


    Ultrasound guided by the patients area of maximal tenderness may reveal a rounded, noncompressible, hyperechoic mass, without internal vascularity, and surrounded by a subtle hypoechoic line 5. They are typically 2 - 4 cm in maximal diameter.

    They typically exert local mass effect but are not usually associated with bowel wall thickening or ascities 5.


    CT appearances are usually characteristic consisting of:

    • a fat-density ovoid structure adjacent to colon, usually 1.5- 3.5cm in diameter 2

    • thin high-density rim (1-3mm thick) 5-6

    • surrounding inflammatory fat stranding, and thickening of the adjacent peritoneum

    • central hyperdense dot (representing the thrombosed vascular pedicle) 6

    Chronically, an infarcted appendix epiploica may calcify, and may detach to form an intraperitoneal loose body. It may involve the vermiform appendix epiploic appendages, therefore mimicking tip appendicitis both clinically and potentially on CT.


    Although not frequently performed for this indication MRI features are also characteristic 6:

    • T1 - often shows a rounded high signal mass with slightly reduced signal compared to normal fat, due to inflammatory stranding ; hypointense 2-3 mm rim

    • T2 - often seen as a high signal mass which attenuates on fat suppressed sequences ; hyper-intense 2-3 mm rim with surrounding high signal stranding ; central low signal vein

    • T1 C+ (Gd) - shows vivid rim enhancement

    Treatment and prognosis

    Epiploic appendagitis is a self limiting disease, and thus correct identification on CT prevents unnecessary surgery 2. Although it sometimes mimics acute abdominal diseases for which surgery is required, treatment options for epiploic appendagitis often do not include surgery,

    Differential diagnosis

    Imaging differential considerations include

    • acute appendicitis - if right sided

    • diverticulitis

    • mesenteric panniculitis

    • omental neoplasms - e.g exophytic angiomyolipoma, atypical liposarcoma

    • omental infarction