Epiploic Appendagitis: Symptoms, Types, Causes and Treatment

Epiploic appendagitis is a rare and often misdiagnosed cause of acute abdominal pain. It mimics more common conditions like appendicitis and diverticulitis, leading to unnecessary interventions and anxiety if not properly identified. Understanding its symptoms, types, causes, and optimal treatment options is crucial for both patients and healthcare providers. This comprehensive article offers a detailed, evidence-based guide to epiploic appendagitis, ensuring you gain a clear understanding of this intriguing yet benign abdominal disorder.

Symptoms of Epiploic Appendagitis

Epiploic appendagitis typically presents with acute abdominal pain, but its symptoms can be deceptively similar to other, more serious abdominal conditions. Recognizing its unique symptom profile is essential for differentiating it from emergencies that require surgery.

Pain Location	Onset	Associated Symptoms	Source(s)
Lower abdomen	Sudden	Rarely fever/nausea	1 2 3 4 5 6
Left/right flank	Acute	Mild/no leukocytosis	1 4 5 7 8 9
Well-localized	Recent	No peritoneal signs	1 2 4 6 7
Tenderness	Subacute	Normal labs common	1 4 5 7

Table 1: Key Symptoms of Epiploic Appendagitis.

Clinical Presentation: What Patients Experience

Epiploic appendagitis most often causes sharp, focal abdominal pain. This pain is usually sudden in onset and located in the lower left or right quadrant, but can also be central or in the upper abdomen. Unlike appendicitis or diverticulitis, the pain tends to be very localized—patients can often point to a specific, small area where it hurts most 1 4 5 6. The pain may worsen with movement or deep breathing, but is generally persistent and non-radiating.

Associated and Distinguishing Symptoms

While epiploic appendagitis can cause mild tenderness on examination, it rarely presents with the more alarming signs of acute abdomen such as:

• Fever
• Significant nausea or vomiting
• Guarding or rebound tenderness
• Marked leukocytosis (elevated white blood cell count)

Most laboratory tests, including inflammatory markers, are normal or only mildly elevated 1 4 7 8. This is a key clue: in contrast, both diverticulitis and appendicitis often present with fever and high white blood cell counts 1 2 4.

Mimics and Diagnostic Challenges

The overlap in symptoms between epiploic appendagitis and other abdominal emergencies leads to frequent misdiagnosis and unnecessary hospitalization or surgery 1 2 4 5 6 12. Imaging—most commonly a CT scan—is essential for accurate identification 1 6 11 12.

Types of Epiploic Appendagitis

Although epiploic appendagitis is a single disease entity, it is classified into two main types based on underlying cause and association with other conditions.

Type	Description	Commonality	Source(s)
Primary	Spontaneous inflammation (torsion/thrombosis)	Most frequent	1 4 8 12
Secondary	Inflammation due to nearby disease (e.g., colitis, diverticulitis)	Less common	8 12 15

Table 2: Types of Epiploic Appendagitis.

Primary Epiploic Appendagitis

Primary epiploic appendagitis is the most common type. It arises from spontaneous torsion (twisting) of an epiploic appendage or thrombosis (clotting) of its draining vein. This leads to localized ischemia and sterile inflammation of the appendage itself 1 4 8 12. There is no preceding or associated intra-abdominal infection or inflammatory disease.

Features include:

• Sudden onset, localized pain
• Absence of underlying bowel disease
• No systemic symptoms

Secondary Epiploic Appendagitis

Secondary epiploic appendagitis occurs as a result of adjacent inflammation or infection—such as diverticulitis, appendicitis, or colitis—spreading to the epiploic appendages 8 12 15. In these cases, the appendagitis is not the primary disorder but an extension of another intra-abdominal process.

Characteristics of secondary type:

• Pain may be less well-localized
• Systemic symptoms (fever, elevated white count) may be present due to the primary disease
• Imaging shows both the primary condition and inflamed appendage

Rare Presentations and Complications

Rarely, epiploic appendagitis can be complicated by abscess formation or may present within a hernia sac. Chronic infarction can eventually result in a calcified loose body within the abdomen. Complicated cases are very rare and typically arise only if diagnosis is delayed or in immunocompromised patients 11 16.

Causes of Epiploic Appendagitis

Understanding what triggers this unique abdominal syndrome helps clinicians suspect and diagnose it earlier. The causes are directly related to the anatomy and vascular supply of the epiploic appendages.

Cause	Mechanism	Risk Factors	Source(s)
Torsion	Twisting of appendage	Obesity, activity	1 3 4 5 8
Venous Thrombosis	Clot in draining vein	Vascular disease	1 3 4 5 15
Inflammation	Extension from nearby disease	Diverticulitis, colitis	8 12 15 16

Table 3: Causes of Epiploic Appendagitis.

Anatomy and Function of Epiploic Appendages

Epiploic appendages are small, fat-filled pouches of peritoneum that hang from the outer surface of the colon. They are most numerous in the sigmoid and cecal regions 3 4 13. Their exact function is not well understood, but they are thought to play a minor role in cushioning and immune surveillance of the colon 13.

Primary Causes: Why Do Appendages Become Inflamed?

The two main mechanisms behind primary epiploic appendagitis are:

• Torsion: The appendage twists on its narrow stalk, cutting off blood flow. This leads to ischemia (lack of oxygen) and subsequent infarction (tissue death), triggering localized inflammation 1 3 4 5.
• Venous Thrombosis: A clot forms in the central draining vein of the appendage, similarly causing ischemia and inflammation 1 3 4 5.

Both mechanisms are more likely in individuals with:

• Obesity (due to larger or more numerous appendages)
• Sudden movements or increased intra-abdominal pressure
• Middle age (peak incidence in 30s-50s) 4 5 15

Secondary Causes: Inflammatory Spread

Secondary epiploic appendagitis occurs when inflammation from a nearby condition (most often diverticulitis, appendicitis, or colitis) spreads to the appendages 8 12 15 16. In these cases, the appendagitis is not the primary disease and is usually overshadowed by the symptoms of the underlying disorder.

Rare and Complicated Causes

Rarely, trauma or prior abdominal surgery can contribute to appendage torsion or infarction. Chronic infarcted appendages may calcify and detach, resulting in "peritoneal loose bodies" 11.

Treatment of Epiploic Appendagitis

One of the most important aspects of epiploic appendagitis is its self-limiting nature. With the right diagnosis, patients can avoid unnecessary interventions and recover quickly.

Management	Approach	Indications	Source(s)
Conservative	Analgesics, NSAIDs	Uncomplicated cases	2 4 5 10 12
Antibiotics	Rarely used	Possible infection/abscess	5 10 13
Surgery	Resection/drainage	Severe complications	5 11 16

Table 4: Treatment Options for Epiploic Appendagitis.

Conservative (Non-Surgical) Management

Most cases of epiploic appendagitis resolve spontaneously within 1–2 weeks 2 4 5 10 12 15. Treatment focuses on:

• Pain relief: Non-steroidal anti-inflammatory drugs (NSAIDs) or acetaminophen are usually sufficient.
• Rest and hydration: Patients are encouraged to rest and maintain fluid intake.
• Outpatient care: Hospitalization is rarely required unless diagnosis is unclear or complications arise.

When Are Antibiotics Needed?

Antibiotics are generally not indicated, as the inflammation is sterile (not caused by bacteria). However, in rare cases where infection develops—such as abscess formation or signs of generalized peritonitis—antibiotics may be prescribed 5 10 13.

Surgical Intervention

Surgery is reserved for rare, complicated cases:

• Abscess formation not amenable to drainage
• Bowel obstruction
• Persistent or worsening symptoms despite conservative treatment 5 11 16

Even in these instances, minimally invasive techniques such as laparoscopic resection or percutaneous drainage are preferred 16.

The Importance of Accurate Diagnosis

With increasing use of CT and ultrasound, correct diagnosis rates have improved, allowing most patients to avoid unnecessary surgery or prolonged hospitalization 2 7 10 11 12 15. Education and awareness among healthcare providers are crucial to reducing inappropriate antibiotic use and surgical interventions.

Conclusion

Epiploic appendagitis is a benign but often misdiagnosed cause of acute abdominal pain. Prompt recognition and appropriate management are essential to avoid unnecessary procedures and provide reassurance to patients.

Key Takeaways:

• Epiploic appendagitis presents as sudden, localized lower abdominal pain, often without fever or significant lab abnormalities 1 2 4 5 6.
• It is classified as primary (spontaneous) or secondary (associated with other abdominal inflammation) 8 12 15.
• Causes include torsion or venous thrombosis of the epiploic appendages and, less commonly, spread from nearby inflammatory disease 1 3 4 5 8 12 15.
• Diagnosis is made with imaging (CT or ultrasound); laboratory tests are usually unremarkable 1 6 7 10 11 12.
• Treatment is nearly always conservative, with pain control and observation; antibiotics and surgery are rarely needed 2 4 5 10 13 16.
• Improved clinician awareness and imaging use can prevent unnecessary hospitalizations and surgeries 2 5 7 10 11 15.

Understanding the unique features of epiploic appendagitis empowers patients and clinicians to make informed decisions, ensuring optimal outcomes with minimal intervention.