Torsion of the epiploic appendix : An unusual cause of acute abdomen

of 1320 cases of acute abdominal pain by Golash only eight cases were due to acute epiploic Summary: Torsion of an epiploic appendix is a rare surgical entity.We present our experience in a thirty appendagitis. The site of pain may vary according to five year old female patient and a forty year old the position of the inflamed appendage. Hence, it male patient. Materials and Methods: A 35 year may mimic acute appendicitis, acute cholecystitis or old lady had presented with right iliac fossa pain of acute diverticulitis. 2 days duration. Guarding and rebound tenderness was present over the area. Investigations showed mild leucocytosis and neutrophilia. Diagnostic We report two cases where the clinical presentations laparoscopy revealed an inflamed epiploic appendix mimic acute appendicitis. It was only on diagnostic which was excised. Other intrabdominal organs were laparoscpy that gangrenous appendix epiploicae on normal. A 40 year old male patient had presented the ascending colon was found in both the cases and with a history of recurrent, colicky, and paroxysmal proper management by excision of the gangrenous right lower quadrant pain for 2 months. At epiploicae undertaken. laparoscopy, an inflamed torted epiploic appendix of the ascending colon was detected and excised. Other intrabdominal organs were normal. Results: So we suggest that though rare but epiploic Both the patients had an uneventful recovery and appendigitis if present may closely mimic acute are asymptomatic at follow up of 10 and 7 months appendicitis and should be looked for if the appendix respectively.They have been followed up at 7 days, 4 wks and then 3 monthly. Discussion: The clinical is found normal per-operatively.


INTRODUCTION
Torsion of an epiploic appendix is a rare surgical entity that presents with abdominal pain.In a series laparoscopy since many pathologies closely mimics appendicitis.

CASE REPORTS
Case 1 A 35-year-old female patient presented to the surgical outpatient department with a history of right lower quadrant pain for two days.She had a history of bouts of vomiting and associated low-grade fever for one day.There was no history of constipation, bleeding per anum or abdominal trauma.There was no major ) .In view of the clinical presentation, she was provisionally diagnosed to be suffering from acute appendicitis.Laboratory and screening tests were inflammation was identified.The inflamed epiploic appendix had undergone gangrenous torsion.The epiploic appendix was excised with Ultrasonic Shears.Examination of the remaining intraabdominal organs was performed -no other disease process was identified.A local lavage was performed with warm normal saline, the lavage fluid was aspirated and the abdominal cavity was desufflated.
Case 2 asked for and parenteral antibiotics, analgesics etc A 40-year-old male patient presented with a history were administered.She was allowed nothing per of recurrent, paroxysmal, colicky right lower quadrant orally and intravenous fluids were administered.
pain association with nausea and vomiting for two months.The last episode of pain was four days before Ultrasonogram was unremarkable but the laboratory the initial assessment; there was no history of trauma, results showed mild leucocytosis (11,500/cm) with constipation, diarrhea or bleeding per anum.On neutrophilia (78%).Since the pain was not getting examination, there was marked tenderness over the controlled, a decision to perform diagnostic right lower quadrant and Rovsing's test was positive.laparoscopy under General Anesthesia and proceed Provisionally, the patient was diagnosed as a case of further was taken.
recurrent appendicitis with an acute episode.Pelvic and lower abdominal Ultrasonogram During laparoscopy, the vermiform appendix was unremarkable and laboratory parameters were found to be normal.The ileocaecal junction was within normal limits.identified and distal ileum was examined for about 60 cm -the ileum was healthy, there was no A diagnostic laparoscopy was performed under lymphadenopathy and Meckel's general anesthesia.A normal-looking pelvic diverticulum was not detected.
vermiform appendix was identified.The distal ileum and mesentry were also normal.Inflammation was Examination of the ascending colon revealed a identified in the ascending colon and adhesions to phlegmon of 4 cm size in the anterior surface.On the greater omentum were present at the proximal gentle dissection, a swollen inflamed gangrenous ascending colon.On adhesiolysis with a Ultrasonic epiploic appendix [Figure 1] with adjacent serosal Shear an inflamed gangrenous, torsioned epiploic appendix was identified at the anteromedial part of proximal ascending colon.Excision of the appendage was mesenteric was performed and the abdominal cavity was desufflated after a local lavage with warm saline.
Both the patients had an uneventful postoperative period.The patients were discharged on the third and the fourth postoperative days respectively.Histopathological examination confirmed a gangrenous epiploic appendix in both patients.
Bandyopadhyay et al.: Torsion of the epiploic appendix in two axial rows from the caecum to the distal sigmoid colon.A normal adult human being usually has about 50-100 appendices epipoloicae.Primary epiploic appendagits is a rare condition, [1] in which torsion and inflammation of an epiploic appendix may cause localized abdominal pain.Epiploic appendagits usually occurs due to spontaneous venous thrombosis or torsion followed by hemorrhagic infarction, fatty necrosis, inflammatory reaction and subsequent peritoneal irritation.The disease commonly occurs in the adult population.
detection and treatment (by excision) has been reported from several centers.Though conservative treatment has been advocated by some centers, [7,8] a computerized tomographic scan (CT scan) was pivotal in formulating the principles of treatment. [9,10]In a developing country like ours where advanced scanning systems are not available everywhere, a diagnostic laparoscopy remains an accurate, safe and cost effective means of diagnosis which provides simultaneous therapeutic options at no increased expenditure.
The commonest site of epiploic appendagits is in the Torsion of an epiploic appendix is a rare disease entity sigmoid colon followed by the caecum.
that may present with a confusing clinical spectrum and hence is difficult to diagnose.Diagnostic The site of pain may vary depending on the location laparoscopy is a good treatment modality in such of the appendage involved.Thus the disease may patients with abdominal pain but with an elusive mimic acute appendicitis, acute cholecystitis or acute diagnosis.Laparoscopy not only allows the surgeon diverticulitis.However, in contrast to diverticulitis to diagnose a torted epiploic appendix but allows the which shows mild smooth bowel thickening without patient a benefit of simultaneous surgical treatment.lymphadenopathy, epiploic appendagits shows up as central areas of high attenuation and a hyper REFERENCES attenuated rim in proximity to the colon. [2] Golash V, Willson PD.Early laparoscopy as a routine procedure in the management of acute abdominal pain: A review of 1320 Chronic torsion of an epiploic appendix has been deaths relating to the disease have also been reported 3. Osdachy A, Shapiro-Feinberg M, Zissin R. Strangulated small bowel in literature. [4]However torsion of an epiploic obstruction related to chronic torsion of an epiploic appendix: CT findings.Br J Radiol 2001;74:1062-4.
appendix is seldom diagnosed preoperatively. of peritoneal cavity will establish the correct diagnosis and the treatment can be provided during the same procedure. [6] operation, depending on the amount of torsion and / or inflammation several different findings may be possible -a phlegmon, a gaseous epiploic abscess, an infarcted epiploic appendix or a colonic mass.
Diagnostic laparoscopy is now considered a good diagnostic modality that offers an accurate assessment of this obscure pathology with the benefits of minimal risk and rapid recovery.In recent times, laparoscopic

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Legome EL, Bolton AL, Murray RE, Rao PM, Novelline RA.Epiploic Bandyopadhyay et al.:Torsion of the epiploic appendix comorbidity.There was no history of dysuria or leucorrhoea or any menstrual disorder.On examination, there was guarding over the right iliac fossa and mild tenderness over the Mcburney's point.Rebound tenderness was elicited but Rovsing's test, Cope's Psoas Test and Cope's Obsturator tests were negative.