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Case of the Month 5/08

This 23 year old male presented to the ED with 2 days of constant left lower quadrant pain. He had no GI or GU complaints. On exam, he was afebrile, and noted to be focally tender in the left mid-lower abdomen with no guarding or rebound tenderness. He had no hematuria.
Q1: Given the history above and the CT images below, can you name the diagnosis? (this is a tough one but it was covered in the radiology lecture on abdominal CT last year.)

Hints – what type of tissue do you think is making up the circular structure with the white edges (inside of the red circle)?

View answer

Answer 1:

Epiploic appendagitis. Epiploic appendages are fat-containing outpouchings which are attached to the serosal surface of the colon. They occasionally become inflamed due to torsion or thrombosis and cause sudden onset of right lower or left lower quadrant pain which may mimic appendicitis or diverticulitis. GI symptoms are more likely to be absent however and the pain is typically more acute in onset in these cases. The red circle is around the classic CT finding of epiploic appendagitis – a circular or ovoid lesion which is made of fat (note that the gray color of that tissue matches the subcutaneous fat and is clearly not a diverticula extending from the colonic lumen) with a hyperdense rim around it. There is also a small amount of surrounding fat stranding. While this is a fairly uncommon diagnosis, it is important to be aware of as (unlike appendicitis and diverticulitis), the treatment is conservative (pain management only).