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Revista Imágenes 03 Sección para residentes CT A F N: E A M D D Jorge Ahualli Abstract Resumen Abdominal fat necrosis may cause pain, mimic findings of acute ab - La necrosis grasa abdominal puede causar dolor, simular un abdo - domen, or be asymptomatic and accompany other pathophysiologic men agudo o ser asintomática y acompañarse de otros procesos fi - processes. Common processes that are present in fat necrosis include siopatológicos. Alteraciones que comúnmente se relacionan a torsion of an epiploic appendage (a self-limited inflammation of the necrosis grasa abdominal incluyen la torsión de un apéndice epi - appendices epiploicae), infarction of the greater omentum (a he - ploico (un proceso inflamatorio autolimitado de los apéndices epi - morrhagic infarction resulting from vascular compromise), encap - ploicos), infarto del omento mayor (un infarto hemorrágico sulated fat necrosis (traumatic or ischemic insult that causes fat resultante del compromiso vascular del omento), necrosis grasa en - degeneration), fat saponification and pancreatitis and heterotopic capsulada (afección traumática o isquémica que causa degenera - ossification in surgical incisions of the abdomen (represent a subtype ción grasa), saponificación grasa y pancreatitis y osificación of traumatic myositis ossificans in which osseous, cartilaginous, and, heterotópica vinculada a incisiones quirúrgicas del abdomen (un occasionally, myelogenous elements forms within a surgical inci - subtipo de miositis osificante traumática en la que elementos óseos, sion). cartilaginosos y ocasionalmente mielógenos se forman en una in - cisión quirúrgica). Key words: necrosis, fat, abdominal. Palabras claves: necrosis, grasa, abdomen. Epiploic appendagitis Epiploic appendices: Normal Imaging Aspect and Anatomy Epiploic appendices constitute small invaginations of the visceral peritoneum containing fat and small blood vessels. They start in the serous surface of the colon adjacent to teniae coli (from the cecum to the recto - sigmoid junction) and they are more abundant in the left colon and cecum (1,2) and not present in the rec - tum. Since they are mixed with the surrounding peri - colic fat they are not usually identified with computed tomography except when they are surrounded by li - quid (Fig 1) (3-6). Datos de contacto: Jorge Ahualli. Centro Radiológico Luis Méndez Collado. Recibido: de Agosto de / Aceptado: de Octubre de San Miguel de Tucumán. Tucumán. - Argentina. Recieved: August , / Accepted: October , e-mail: [email protected] Revista Argentina de Diagnóstico por Imágenes Epiploic Appendagitis and its Main Differential Diagnosis Ahualli, J. Fig. : Epiploic appendices. a-b A) Macroscopic image showing an epiploic appendix of the sigmoid colon with many adipose content and vascular structures inside (Arrow). B) CT of a patient with ascites due to peritoneal carcinomatosis where epiploic appendices of the sig - moid colon can be identified as tubular structures with fat density (Arrows). Epiploic Appendagitis: Due to the absence of pathognomonic characte - Pathophysiology and Clinical Aspects ristics, it is often difficult to diagnose EA clinically, Epiploic appendices can spin on their axis or have so imaging studies are become essential, not only spontaneous central venous thrombosis. Both pro - to determine the diagnosis but also to establish the cesses determine vascular occlusion with inflamma - most appropriate treatment (3,12,15). tion and eventually acute ischemic infarct of the affected epiploic appendix, (1) recently recognized condition, (7) called epiploic appendagitis (this is Epiploic Appendagitis: Tomographic Aspect the preferred term as opposed to epiploic appen - In CT, infarcted epiploic appendix is presented as dicitis to avoid confusion with acute cecal appen - a small (1-4 cm), oval, and pericolonic focal area dicitis) (4, 8-10). Even though this process may with fat density (-40 to -120 Hounsfield units), ge - occur in a spontaneous way, extreme exercise has nerally surrounded by a thin (1-3 mm) dense ring been reported as a predisposing factor (11-13). (sign of the hyperdense ring) that represents the The age in which the process becomes present visceral peritoneum covering the epiploic appen - varies from 12 to 82 years of age, with a maximum dice, inflamed generally in relation to sigmoid incidence in the fifty-year-old people, more com - colon (Fig 2) (16,17). monly in obese people and women (3, 12). Typi - With less frequency, a dense area, not well defi - cally, Patients suffer from acute abdominal pain (not ned, rounded or lineal (Dot sign or Central Line migrating, it intensifies with coughing and without sign), can be identified inside the lesion, correspon - abdominal defense), generally situated at the left ding to central thrombosed vessels, to hemorrhage iliac fossa (more frequently in relation to sigmoid, areas or fibrosis (Fig 3). Although the presence of then ascendant, descendant and not frequently in these signs is useful for the diagnosis, its absence the transverse) associated with slight abdominal dis - does not exclude EA diagnoses (4,7,12,13,16,18-20). tension (3,7,11,14) and patients can suffer from a Less frequent findings include: a greater increase low-grade fever (3, 15). Appetite and abdominal in the density of the pericolonic adipose tissue than function are not generally modified, and nausea the wall thickening of the adjacent colon (due to and vomiting are not frequent (13,15). In lab analy - associated inflammatory changes) (Fig 4); extrinsic ses, the quantity of white blood cells is normal or compression of the adjacent colonic wall and fascial slightly increased of white blood cells (11). and secondary parietal peritoneum thickening se - Vol. / Nº - Diciembre, . Epiploic Appendagitis and its Main Differential Diagnosis Ahualli, J. condary to inflammatory condition (Fig 5) (3- the last necrosis the one that most frequently pre - 8,12,16,21,22). sents peripheral calcifications (or eggshell) (Fig 9) With less frequency, those findings can be seen (23). With less frequency, they can present central in relation to ascendant and descendant colon (FI - calcification surrounded by a peripheral ring of fi - GURE 6), being CT an essential diagnosis tool for brous tissue (24). Cases of epiploic appendices as the differentiation of this process from other abdo - sequela have been reported. They were calcified, minal acute conditions (for example, acute appen - avulsioned and present in the abdominal cavity as dicitis or acute peridiverticulitis). Cases of EA have lost intraperitoneal bodies (3,15,21,25). These intra - even been reported in eventration or hernial sac peritoneal bodies can even be attached to structures with intestinal content (Fig 7) (3,4,15). or organs (more commonly to the inferior surface In other occasions, the inflammatory and ische - of the spleen); in these cases, they are called para - mic process involving the epiploic appendix is a sitic epiploic appendices (3). The smooth surface consequence of the direct involvement in another and the calcified consistency of EA help distinguish neighboring inflammatory process (more frequently them from other omental lesions, especially from acute peridiverticulitis, appendicitis, cholecystitis, metastasis (6). etc.); this condition is a secondary epiploic appen - dagitis (8,11,12,21). In these cases, the findings of the cause should be added to the findings above mentioned (Fig 8). As it evolves, the affected epiploic appendix can show several aspects which vary from a focal area with soft tissue density to a focal area with fat den - sity and to residual encapsulated fat necrosis, being Fig. : a-b Epiploic Appendagitis. CT showing an oval formation, in relation to the sigmoid colon (SC), with fat density corresponding to an inflamed ischemic epiploic appendix. The image is surrounded by a dense halo corresponding to inflamed visceral peritoneum (Arrow). Revista Argentina de Diagnóstico por Imágenes Epiploic Appendagitis and its Main Differential Diagnosis Ahualli, J. Fig. : Dot sign or Central a-b Line sign. Axial view (A) and sagittal multiplanar reconstruction (B) showing an oval image with fat density, surrounded by a peripheral dense ring corresponding to epiploic appendagitis. Note that in - side, there is a dense lineal image co - rresponding to the thrombosed central vessel (Arrow). Fig. : Associated inflammatory changes. a b A) Ultrasound image of left iliac fossa showing a com - c pressible echogenic oval formation (Arrows). Axial view B) and sagittal multiplanar reconstruction (B) showing a fat density oval image, surrounded by a peripheral dense ring corresponding to epiploic appendix infarction. Note the increase in density of the surrounding adipose tissue due to the presence of inflammatory perilesional changes (Arrows). Fig. : Fascial thickening. a-b Coronal (A) and sagittal (B) multipla - nar reconstruction of a patient with epiploic appendagitis (*). Note the in - crease in density of the adipose tissue surrounding the epiploic appendix and lateroconal and homolateral fascia thickening (Arrows), also known as "comma sign". Vol. / Nº - Diciembre, . Epiploic Appendagitis and its Main Differential Diagnosis Ahualli, J. Fig. : Right epiploic a-b appendagitis. A) Ultrasound transversal image of right iliac fossa showing a non-com - pressible echogenic oval image (arrows). B) CT shows a flame epiploic appendix surrounded by a dense ring correspon - ding to inflammatory visceral perito - neum (Arrow). Its typical appearance determines the differential diagnosis with
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