1. DATE
TOPIC
PARTICIPENT
1-Feb-09
intersting cases
all residents
8-Feb-09
case review
maram
15-Feb-09
interesting cases
22-Feb-09
topic presentation
alhawas
1-Mar-09
interisting cases
all residentis
8-Mar-09
ACR case review
sultan
15-Mar-09
22-Mar-09
OSCE
alosaimi
29-Mar-09

2. Case review
Maram Mobara

3. 18 years old obese male
Presented to the ER with RIF pain
For 2 days
Difficult exam due to obesity, no typical rebound tendrness
WBS: slightly elevated.

4. CT abdomen requested to rule out acute appendicitis
CT scan was performed utilizing pancreatitis protocol

5. Findings

9. Acute epiploic appendagitis
Omental infarction
Subacute appendicitis

10. Management Exploratory laparoscopy Unremarkable appendix
Fatty mass adherent to the wall of ascending colon with enlarged inflamed appendages
Pathological result:

12. DIFFERENTIAL DIAGNOSIS
Inflammatory mass lesion in patient with acute abdomen

13. acute epiploic appendagitis,
acute omental infarction,
acute inflammatory process such as diverticulitis,
sclerosing mesenteritis, and
primary tumor or metastasis that involves the mesocolon.

14. Acute epiploic appendagitis

15. Normal Epiploic Appendages
Peritoneal pouches from serosal surface of the colon
Attached to by vascular stalk
Composed of adipose and vascular tissue
Each one is supplied by 2 arteries and one vein cm
Seen on CT only if inflamed

17. Causes of acute epiploic appendagitis
torsion and inflammation (73%),
hernia incarceration (18%),
intestinal obstruction (8%), and
Intra peritoneal loose body.

18. Association
Obesity , ★
hernia, and
unaccustomed exercise

19. Clinically 4th- 5th decay Men ★ Acute onset pain ★
LLQ (acute diverticulitis)
Most normal body temp and WBC

20. self-limited inflammation,
before CT was available, was most commonly diagnosed at surgery

21. CT FINDINGS most common sites, in order of decreasing frequency
areas adjacent to the sigmoid colon
descending colon,
right hemi colon ★

22. oval lesion less than 5 cm in diameter
attenuation equivalent to that of fat
abuts the anterior colonic wall,
surrounded by inflammatory changes

25. 2ndary changes: peritoneal inflammation and colonic wall thickening,
Intestinal obstruction and abscess formation are rare.
Although the presence of a central area of high attenuation due to venous thrombosis is useful for diagnosis, the absence of this feature does not preclude a diagnosis of acute epiploic appendagitis
Rarely, appendagitis may occur in a hernia sac .

29. RIF

30. No hyper attenuation center

32. Evolutionary changes

33. US FINDINGS
an oval non compressible hyper echoic mass at the site of maximum tenderness, adjacent to the colon,
with no central blood flow on color Doppler US images

35. Mimics of acute epiploic appendagitis

36. Omental infarction Rare cause of acute abdomen
RIF pain, ? Appendicitis
>>> pediatrics

37. Causes: torsion> venous insufficiency> infarction
Predisposing factors to insufficiency :
obesity ,
CHF and
recent abdominal surgery.

38. OMENTAL INFARCTION CT FINDINGS :
solitary large non enhancing omental mass
heterogeneous attenuation
located in the right lower quadrant, deep to the rectus abdominis muscle and either anterior to the transverse colon or anteromedial to the ascending colon

41. Acute omental infarction in young female

42. Omental infarction Vs epiploic appendagitis Larger than 5cm Location
+/-Lack of ring enhancement and central hyperattenuation

43. Acute diverticulitis

44. Acute diverticulitis Older age group
nausea, vomiting, fever, elevated leukocyte count, and rebound tenderness

45. Acute diverticulitis CT FEATURES:
colonic diverticula with inflammation or abscess in the mesocolon
adjacent colonic wall thickening that extends more than 5 cm
Other un inflamed diverticulae
Fat stranding, extra luminal air or fluid accumulation, or abscess formation around the colonic lumen

46. ★

47. With 2ndary epiploic appendagitis

48. Sclerosing Mesenteritis

49. Sclerosing Mesenteritis
Non specific inflammation and fibrosis of the fatty tissue of the mesentery
typically occurs in the 6th to 7th decades of life.
The cause in most cases is unknown.
acute abdominal pain, fever, nausea, vomiting, diarrhea, and weight loss.
In the majority of cases, the disease is self limited and the prognosis is favorable.

50. Sclerosing Mesenteritis
CT FEATURES:
well-defined soft- tissue mass containing areas of fat attenuation to an ill-defined area of higher attenuation
in the root of the small-bowel mesentery
around mesenteric vessels with- out displacing them.
The fat plane around the mesenteric vessels results in a CT feature that is called the “fat ring sign.”

51. Fibrosis may lead to bowel loop narrowing and result in spiculation that may be mistaken for a neoplastic process.
Calcification are uncommon

55. Vs epiploic appendagitis
Larger
Root of mesentery, doesn’t abut the abdominal wall
Not usually cause of acute abdomen
Central hyper attenuation

56. Primary tumors and metastasis

57. fat-containing tumors such as liposarcoma, as well as exophytic angiomyolipoma and dermoid
omental metastases

58. Summary Acute appendagitis is self limiting condition
Commonly confused cliniclly with appendicitis
CT findings decrease rate of unnecessary operation and hospital admission.
Obese, male, 4th-5th decay of life with acute abdomen
No leukocytosis

59. CT: 5cm oval fat containing lesion
Abuts bowel loop surface
Central hyperattenuation
Surrounding peritoneal inflammation.

60. THANK YOU