Home | About Us | Current Issue | Ahead of print | Archives | Search | Instructions | Subscription | Feedback | Editorial Board | e-Alerts | Login 
Journal of Indian Association of Pediatric Surgeons
     Journal of Indian Association of Pediatric Surgeons
Official journal of the Indian Association of Pediatric Surgeons         
 Users Online:158 
  Print this page Email this page   Small font sizeDefault font sizeIncrease font size


 
CASE REPORT
Year : 2008  |  Volume : 13  |  Issue : 2  |  Page : 83-84
 

Appendicitis epiploicae: An unusual cause of acute abdomen in children


Departments of Pediatric and Neonatal Surgery, Ibn Sina Hospital, Kuwait

Correspondence Address:
Vipul Gupta
Department of Pediatric Surgery, State of Kuwait
Kuwait
Login to access the Email id

Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0971-9261.43035

Rights and Permissions

 

   Abstract 

Appendicitis epiploicae is described as a rare entity in an 8-year-old boy presented with the features of acute abdomen simulating acute appendicitis. Surgical exploration revealed a torsion of appendices epiploicae of the cecum. The excision of infarcted epiploicae with seromuscular inversion resulted in satisfactory recovery. Authors describe this uncommon cause of pediatric acute abdomen along with the review of pertinent literature.


Keywords: Acute abdomen, appendicitis epiploicae, children


How to cite this article:
Gupta V, Kumar S. Appendicitis epiploicae: An unusual cause of acute abdomen in children. J Indian Assoc Pediatr Surg 2008;13:83-4

How to cite this URL:
Gupta V, Kumar S. Appendicitis epiploicae: An unusual cause of acute abdomen in children. J Indian Assoc Pediatr Surg [serial online] 2008 [cited 2017 May 28];13:83-4. Available from: http://www.jiaps.com/text.asp?2008/13/2/83/43035



   Introduction Top


Appendicitis epiploicae is an extremely uncommon intraabdominal inflammatory pathology resulting from the infarction of appendices epiploicae secondary to its torsion or thrombosis. [1],[2],[3] Most of the disorders of appendices epiploicae are reported in the middle-age group with the involvement of appendages of the transverse and sigmoid colon. [1],[2],[3] However, the involvement of cecal appendages remains clinically significant as the clinical presentation mimics acute appendicitis and is rarely diagnosed preoperatively.[1],[2] Moreover, appendicitis epiploicae has rarely been described in the pediatric age group with only handful of cases reported in English literature to date. [1],[2],[3],[4],[5] Since the clinical presentation is not pathognomic, the diagnosis is rarely performed preoperatively and is often confused with acute appendicitis. [1],[2],[3] Thus, we herein report the present case with the aim to spread awareness to the physicians regarding the clinical presentation and management protocol of this unusual cause of pediatric acute abdomen.


   Case Report Top


An 8-year-old male child presented with 1 day history of the sudden onset of acute pain in the right lower abdomen, which was associated with nausea, few episodes of vomiting and a low-grade fever.

On examination, the child had a temperature of 37.2C, pulse rate of 110/min and blood pressure of 124/76 mm Hg. Systemic examination revealed no abnormality, except for the presence of tenderness with guarding at McBurney's point. Digital rectal examination was normal. Laboratory investigations suggested mild leukocytosis with a WBC count of 11000/mm 3 and 82% polymorphs on differential count. Ultrasound examination of the abdomen suggested minimal free fluid in right iliac fossa with normal solid viscera and the appendix was not visualized.

A provisional diagnosis of acute appendicitis was considered and the patient was taken for surgical intervention. Surgical exploration was performed through Lanz incision, which revealed the presence of approximately 10 ml of serosanguinous fluid in the right iliac fossa with an appendix with normal appearence. Further exploration revealed the presence of gangrenous appendix epiploica on the surface of the cecum. The infracted appendage was excised with seromuscular inversion of the cecal wall and appendectomy. Histopathology revealed a normal appendix with congested, hemorrhagic and partly necrotic adipose tissue suggestive of appendicitis epiploicae. The postoperative period remained uneventful, and the child was discharged after 48 h.


   Discussion Top


Appendicitis epiploicae is an extremely rare entity in the pediatric age group. [1],[2],[3] It is intraabdominal inflammatory pathology of fatty appendages of colon. These appendages are fatty structures with approximately 2-3 cm in diameter scattered over entire colon with covering of peritoneum and are supplied by single artery and vein. [1],[3] The infarction of these appendages from either torsion or thrombosis results in inflammatory pathology termed as appendicitis epiploicae. [3] The disorders of appendices epiploicae have a peak incidence in the middle-age group with more common involvement of the appendages of transverse and sigmoid colon. [1],[2],[3],[4],[5] However, the involvement of cecal appendages remains clinically significant as it may mimic acute appendicitis. [1],[3] Moreover, appendicitis epiploicae remains an extremely uncommon cause of acute abdomen in pediatric age group, which has been scarcely reported and discussed in English literature to date.

The clinical presentation in cases of appendicitis epiploicae is usually atypical and is heralded by the presence of clinical features and signs of peritoneal irritation localized to right side of abdomen. This is mainly indicated by the sudden onset of abdominal pain localized in right iliac fossa with minimal gastrointestinal symptoms in the form of nausea, vomiting, and low-grade fever. [1],[2],[3],[4]

The laboratory investigations were found to be inconclusive and usually suggest a normal or slightly elevated leukocyte count. [1],[2],[3],[4],[5] Thus, due to the lack of pathognomic clinical features, the diagnosis of this rare entity is rarely considered preoperatively and this condition is most commonly confused with acute appendicitis.

The radiological evaluation in form of abdominal ultrasound examination and CT scan has been found to be useful in preoperative diagnosis in patients with appendicitis epiploicae. [1],[6],[7] A review of literature suggests that the presence of hyperechoic noncompressible ovoid structure near the colonic wall with the absence of blood flow on vigilant sonographic assessment of the abdomen provides the clue to diagnosis. [1],[6] Similarly, CT scan has been found to be useful both for preoperative diagnosis and for further assessment in patients managed conservatively.

The treatment of appendicitis epiploicae is mainly conservative if diagnosed preoperatively. [1],[3] Although most of the cases in adults respond to antibiotics and analgesics, the clinical experience with conservative management in pediatric age group is limited due to nonspecific clinical presentation. Therefore, the diagnosis of uncommon intraabdominal inflammatory pathology is usually apparent at the time of surgical exploration undertaken with a provisional diagnosis of acute appendicitis. [1],[2],[3],[4],[5] Laparoscopy has been found to be useful both as diagnostic and therapeutic intervention in such cases. [3] The excision of the infracted appendage with seromuscular inversion of cecal wall remains the treatment of choice and results in satisfactory recovery.[2],[3]

Thus, appendicitis epiploicae remains an extremely uncommon intraabdominal inflammatory pathology presenting with nonspecific clinical presentation in pediatric age group. We conclude that a high index of clinical suspicion and vigilant radiological assessment may help in providing a clue to diagnosis, and hence, a prompt recovery with conservative management, thereby preventing the morbidity resulting from unnecessary surgical intervention.

 
   References Top

1.Hurreiz HS, Madavo CM. Torsion of an epiploic appendix mimicking acute appendicitis. Saudi Med J 2005;26:2003-4.  Back to cited text no. 1  [PUBMED]  
2.Vazquez-Frias JA, Castaneda P, Valencia S, Cueto J. Laparoscopic diagnosis and treatment of acute epiploic appendagitis with torsion and necrosis causing an acute abdomen. JSLS 2000;4:247-50.  Back to cited text no. 2    
3.O'Rourke RW, Saito JM, Albanese CT. Laparoscopic diagnosis and resection of pediatric appendicitis epiploicae: Case report and literature review. Pediatr Endosurg Innovative Tech 2001;5:319-22.  Back to cited text no. 3    
4.Carmichael DH, Organ CH Jr. Epiploic disorders: Conditions of the epiploic appendages. Arch Surg 1985;120:1167-72.  Back to cited text no. 4  [PUBMED]  
5.Pines B, Rabinovitch J, Biller SB. Primary torsion and infarction of appendices epiploicae. Arch Surg 1941;42:775-87.  Back to cited text no. 5    
6.Hollerweger A, Macheiner P, Hubner E, Rettenbacher T, Gritzmann N. Epiploic appendagitis: Sonographic findings in 28 cases. Ultraschall Med 2002;23:239-44.  Back to cited text no. 6    
7.Barbier C, Denny P, Pradoura JM, Bui P, Rieger A, Bazin C, et al . Radiologic aspects of infarction of the appendix epiploica. J Radiol 1998;79:1479-85.  Back to cited text no. 7  [PUBMED]  [FULLTEXT]



This article has been cited by
1 Epiploic appendagitis of caecum: A diagnostic dilemma [Appendicitis epiploica des blinddarms: Ein diagnostisches dilemma]
Rashid, A. and Nazir, S. and Hakim, S.Y. and Chalkoo, M.A.
GMS German Medical Science. 2012; 10
[Pubmed]



 

Top
Print this article  Email this article
Previous article Next article

    

 
  Search
 
   Next article
   Previous article 
   Table of Contents
  
 
    Similar in PUBMED
   Search Pubmed for
   Search in Google Scholar for
 Related articles
    Article in PDF (45 KB)
    Citation Manager
    Access Statistics
    Reader Comments
    Email Alert *
    Add to My List *
* Registration required (free)  


    Abstract
    Introduction
    Case Report
    Discussion
    References

 Article Access Statistics
    Viewed2830    
    Printed103    
    Emailed1    
    PDF Downloaded188    
    Comments [Add]    
    Cited by others 1    

Recommend this journal


Contact us | Sitemap | Advertise | What's New | Copyright and Disclaimer 

  2005 - Journal of Indian Association of Pediatric Surgeons | Published by Wolters Kluwer - Medknow 

Online since 1st May '05