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Fellows' Corner Fellows’ Corner by Nyree Thorne and Devjit Nayer, assisted by Bonnie Pollack CASE REPORT without rebound tenderness or guarding. Rectal exam 50-year-old woman presented to the emergency revealed normal tone with guiaic negative brown stool. department complaining of two days of left lower Laboratory tests were unremarkable. Enhanced com- Aquadrant abdominal pain and diarrhea. The pain puted tomography scanning of the abdomen (Figure 1) was crampy, intermittent and non-radiating. The demonstrated a paracolic oval mass with peritoneal patient denied nausea, vomiting, hematochezia or thickening (arrow). melena. There was no history of diverticular disease, or any prior abdominal surgery except for c-section. Question 1: What is the most likely diagnosis? The patient had been in good health and denied recent Question 2: What other diagnosis' could this com- travel. monly be mistaken for? On physical examination the patient was afebrile. Question 3: What is the appropriate therapy? There was moderate left lower abdominal tenderness Question 4: Are antibiotics useful in this situation? (Answers and DIscussion on page 56) Figure 1. Nyree Thorne, M.D., Resident, Internal Medicine and Devjit Nayer, M.D., Fellow, Gastroenterology, Winthrop University Hospital, Mineola, NY. With the assistance of Bonnie Pollack, M.D., Assistant Professor of Medicine, SUNY at Stony Brook and Winthrop University Hospital, Mineola, NY. 52 PRACTICAL GASTROENTEROLOGY • JANUARY 2004 Fellows’ Corner (continued from page 52) DISCUSSION diverticulitis and also associated with leukocytosis, Epiploic Appendagitis is an uncommon cause of nausea and fever. Omental infarction, or segmental abdominal pain. It is caused by torsion of an appendage necrosis of the omentum is a rare entity that may or thrombosis of a draining vein. Epiploic appendages mimic the presentation of epiploic appendagitis. Eti- are small pouches of peritoneum filled with soft fat, ologies for omental infarction include anomalous arte- located on the surface of the colon and appendix (1). rial supply to the omentum, kinking veins secondary to Each appendage contains an artery and vein. Rarely increased intra-abdominal pressure and post-prandial these appendages can undergo torsion or thrombosis of vascular congestion have been proposed (3). Com- the draining vein, which can lead to infarction. Infarc- puted tomography findings can help to differentiate tion can cause abdominal pain and mimic more com- these entities. mon causes of abdominal pain, such as acute appen- The treatment of epiploic appendagitis is conserva- dicitis, acute diverticulitis and omental infarction. tive. Initially, patients should remain nil per oral and Epiploic appendagitis is often misdiagnosed as receive intravenous fluids and analgesia. Antibiotics diverticulitis or appendicitis. Son, et al composed clin- have not been shown to be beneficial. Rarely, surg i c a l ical and radiologic characteristics of eight patients exploration is required in patients who do not improve with epiploic appendagitis (2). They were retrospec- with conservative measures. Establishing the correct tively compared with 18 patients with acute divertic- diagnosis is important to avoid unnecessary surg e r y. This ulitis. Patients with epiploic appendagitis had well patient initially received empiric antibiotics for pre- localized tenderness without fever, vomiting or peri- sumed diverticulitis. She improved with conservative toneal signs. Blood tests in these patients were not sig- treatment and was discharged on hospital day four. ■ nificant. Pain was more diffuse in patients with acute References 1 . Morson BC. Morson & Dawson's Gastrointestinal Pathology. 3 r d Edition, Oxford: Blackwell Scientific Publications, 1990; 639. F e l l o w’s Corner is a New Section in 2. Son, et al. Journal of Clinical Gastroenterology, 2002; Clinical Diagnosis of Primary Epiploic Appendagitis, Differentiation Practical Gastroenterology open to form Acute Diverticulitis; 34 (4); 435-438; Lippincott Williams & Wilkins, Inc. Trainees and Residents ONLY. 3. McClure MJ, et al. Radiological Features of Epiploic Appendagi - tis and Segmental Omental Infarction; Clinical Radiology, 2001; Section Editors: C. S. Pichumoni, M.D. 56:819-827. and K. Shiva Kumar, M.D. Send in a brief case report. No more than one PRACTICAL double-spaced page. One or two illustrations, up to 4 questions and answers and a three-quarter to GASTROENTEROLOGY one-page discussion of the case. Case to include no more than two authors. A $100.00 honorarium will be paid per publication. Practical Gastroenterology reprints are valuable, Case should be sent to: authoritative, and informative. Special rates are C. S. Pitchumoni, M.D., available for quantities of 100 or more. Chief, Gastroenterology, Hepatology For further details on rates or to place an order: and Clinical Nutrition Practical Gastroenterology St. Peter’s University Hopsital Shugar Publishing 254 Easton Avenue, Box 591 9 9 B Main Street Westhampton Beach, NY 11978 New Brunswick, NJ 08903 Phone: 631-288-4404 Fax: 631-288-4435 56 PRACTICAL GASTROENTEROLOGY • JANUARY 2004.
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