DOCSLIB.ORG

Bcr-2018-224689.Full.Pdf

Total Page：16

File Type：pdf, Size：1020Kb

Download full-text PDF Read full-text
Bcr-2018-224689.Full.Pdf Findings that shed new light on the possible pathogenesis of a disease or an adverse effect BMJ Case Reports: first published as 10.1136/bcr-2018-224689 on 23 September 2018. Downloaded from CASE REPORT Mast cell deposition and activation may be a new explanation for epiploic appendagitis Leonard B. Weinstock,1,2 Zahid Kaleem,1 Dale Selby,3 Lawrence B Afrin4 1Gastroenterology, GI, SUMMARY volume, visceral adipose area and subcutaneous Washington University, Saint Epiploic appendagitis is as an acute painful condition adipose area in the EA group.8 Louis, Missouri, USA A patient with numerous syndromes and obesity 2 of the fat on the outside of the intestine. Thus far, Department of Medicine, there have been no publications to our knowledge led us to consider that a mast cell (MC) disease was Washington University, Saint responsible for EA and acute and chronic abdominal Louis, Missouri, USA that appendagitis can be caused by mast cells or 3Department of Pathology, can be associated with chronic pain. A patient with pain. MC deposition or activation has not hitherto Missouri Baptist Medical Center, multisystemic disorders suffered with both chronic and been reported in EA. MCs are also thought to play Saint Louis, Missouri, USA acute attacks of abdominal pain for a year. The worst an inflammatory role in the development of obesity 9 4Internal Medicine, Armonk attack led to surgical resection of an enlarged sigmoid which ties into EA. Under normal circumstances, Integrative Medicine, Armonk, colon epiploic appendage. Careful review of her complex MCs are produced from haematopoietic precursors New York, USA medical history and mast cell stains of gastrointestinal in the marrow, circulate briefly in the blood and biopsies led to the diagnosis of mast cell activation soon site themselves in peripheral tissues to guide 10 Correspondence to syndrome. Re-examination of the resected appendage normal growth and development of tissues. The Dr Leonard B. Weinstock, function of normal MCs are to sense insults such as lw@ gidoctor. net using an immunohistochemical stain demonstrated a high mast cell density which is a new histopathological trauma and infection and then quickly respond by finding.T reatment of mast cell activation syndrome and degranulation of premanufactured stores of media- Accepted 28 July 2018 11 other related syndromes led to marked improvement tors. Through interactions with specific receptors in her health, including all types of chronic abdominal on other cells locally and distantly, mediators effect adjustments in function to assist the body with pain. copyright. resistance to, and recovery from, the insult. Patho- logical behaviour from MCs occurs when there are genetic mutations in the regulatory KIT protein and BACKGROUND subsequently disease states develop according to Epiploic appendages are rows of adipose structures the location of MC deposition.12 Gastrointestinal found on the surfaces of the small and large intes- (GI) tract MCs have been associated with burning tine and are composed of fat and have a central mouth syndrome, heartburn, chest pain, nausea, vein and artery and a peritoneal covering.1 Epip- abdominal pain, diarrhoea, constipation and a form http://casereports.bmj.com/ loic appendagitis (EA) can be caused by an idio- of irritable bowel syndrome (IBS).13–16 Proximity pathic inflammatory disease and/or disease caused of MCs to GI sensory nerves and local release of 1 by torsion of the appendage. The classic presen- inflammatory mediators from MCs have been tation is sudden onset of dull or sharp abdominal proposed to explain chronic pain which has been pain which is referred directly from the inflamed demonstrated in man and in animal models.14 15 peritoneal surface of the appendage which usually Mast cell activation syndrome (MCAS) is a 2 is located in the right or left lower quadrant. prevalent, recently recognised, highly heteroge- Attacks of EA occurs in both genders between ages neous syndrome of chronic multisystem polymor- 20 and 50 and generally resolves with conservative bidity.17 18 This syndrome produces general themes therapy; however, it can require hospitalisation of inflammation±allergic type phenomena±abnor- on 25 September 2021 by guest. Protected 3 and, rarely, surgery. Originally thought to be rare, malities in growth and development.19 The same EA is actually relatively common and furthermore it spectrum of effects from chronic inappropriate is often misdiagnosed and can be mistaken for both activation of MCs is seen in the rare disease of 4–7 common acute and recurrent diseases. In a large mastocytosis which is distinguished from MCAS by study, the CT was reviewed retrospectively in 660 neoplastic MC proliferation in the bone marrow 20 © BMJ Publishing Group patients with lower abdominal pain (348 suspected and a high tryptase level. Although autoimmune Limited 2018. Re-use diverticulitis and 312 suspected appendicitis) and mechanisms of primary MCAS likely exist (eg, 4 permitted under CC BY-NC. No 11 (2%) met CT criteria for EA. In a study of 45 via anti-IgE or anti-IgE-receptor autoantibodies), commercial re-use. See rights patients with EA, a presumptive clinical diagnosis and permissions. Published preliminary genetic investigations have demon- by BMJ. was acute appendicitis (n=13), acute cholecys- strated a large menagerie of mutations to be present titis (n=2), acute diverticulitis (n=19), renal colic in the MCs of patients with MCAS in KIT, a trans- To cite: Weinstock LB., (n=7) and ovarian pathology (n=4).7 Obesity is the membrane tyrosine kinase receptor and the domi- Kaleem Z, Selby D, et al. BMJ 1 2 8 12 Case Rep Published Online only identifiable risk factor associated with EA. nant MC regulatory element. Biopsy recognition First: [please include Day A retrospective CT study of 100 patients with EA of MCs is generally not seen by via routine H&E Month Year]. doi:10.1136/ versus 100 patients with acute abdomen demon- staining. It requires special histochemical stains bcr-2018-224689 strated significantly greater abdominal adipose (eg, tryptase, giemsa, toluidine blue, alcian blue) Weinstock LB., et al. BMJ Case Rep 2018. doi:10.1136/bcr-2018-224689 1 Findings that shed new light on the possible pathogenesis of a disease or an adverse effect BMJ Case Reports: first published as 10.1136/bcr-2018-224689 on 23 September 2018. Downloaded from Figure 1 Classic CT scan finding of epiploic appendagitis with a rim- enhancing, oval structure on the exterior of the sigmoid colon located in the right lower abdomen. or, immunohistochemical staining for CD117, the extracellular domain of KIT. One theoretical question raised in this report is whether or not appendages can cause chronic abdominal pain owing to activation of MCs on the peritoneal surface of the intestinal appendage. Our theory is that the MCs cause chronic pain in appendages due to local MC secretion of mediators of copyright. nociception such as histamine, tryptase, cytokines and/or other chemicals. CASE PRESENTATION A 40-year-old Caucasian woman with a history of migraines, gastro-oesophageal reflux, nausea, IBS–diarrhoea and many other idiopathic syndromes suffered with constant abdominal pain with episodic attacks of severe abdominal pain over the http://casereports.bmj.com/ past year. The pain had peaks of labour-like contractions lasting 5 min. This pain was sharp and migratory but most often was located in the right lower quadrant. It was worse with pressure, palpation and movement. Over the same time period, she had worsening headaches, fatigue and cognitive dysfunction. This pain was clearly differentiated by the patient from her 8-year history of IBS which was characterised by postprandial crampy pain, bloating, foul gas and diarrhoea which responded to peri- odic 2-week courses of the antibiotic rifaximin. Over the course of the year, rifaximin was prescribed but did not help this pain. on 25 September 2021 by guest. Protected The patient presented for evaluation in the GI clinic after 4 days of extremely severe, sharp right lower abdominal pain that awoke her from sleep and was associated with a 100oF Figure 2 Immunohistochemical stain showing increased CD117 temperature. The right lower quadrant was markedly tender positive mast cells (MCs) in: (A) terminal ileum with >80 MCs/high- with guarding. The white blood count was normal. The CT was power field (×40/0.65 objective magnification; part of field shown); abnormal (figure 1). Despite administration of acetaminophen (B) epiploic appendage peritoneal surface with 60 MCs/high-power and ibuprofen, the pain worsened and after 7 days of unremit- field (×40/0.65 objective magnification); and (C) control case epiploic ting pain, laparoscopic surgery was performed. Gross findings appendage peritoneal surface with 2 MCs/high-power field (×20/0.65 included an enlarged area of fat near the normal appendix that objective magnification). had a small amount of superficial focal fat necrosis. After surgical resection of the appendage, the right lower pain immediately abated and she was discharged. Standard H&E stain showed prior to this procedure, she endorsed 44 of the 48 symptoms adipose tissue with patchy areas of fat necrosis with repair. The reported most commonly seen in MCAS.19 The colon and ileum appendectomy specimen was normal. were grossly normal. Internal haemorrhoids were present. The Colonoscopy was performed 2 weeks after surgery owing to CD117 stain was used to determine MC density (as described haematochezia. On review of systems obtained immediately in the Investigation section). The ileum had 40–50 diffuse and 2 Weinstock LB., et al. BMJ Case Rep 2018. doi:10.1136/bcr-2018-224689 Findings that shed new light on the possible pathogenesis of a disease or an adverse effect BMJ Case Reports: first published as 10.1136/bcr-2018-224689 on 23 September 2018. Downloaded from 70–80 focal MC/high-power fields (HPF) (figure 2A).
Load more

Recommended publications
  • Beware of Right Lower Quadrant Pain: How Ultrasound Can Help Your Differential Diagnosis
    Beware of right lower quadrant pain: How ultrasound can help your differential diagnosis Poster No.: C-1660 Congress: ECR 2010 Type: Educational Exhibit Topic: GI Tract Authors: C. Ruivo1, M. A. Portilha1, C. Antunes1, I. Santiago2, J. Ilharco1, M. Martins1, F. Caseiro Alves1; 1Coimbra/PT, 2Aveiro/PT Keywords: abdominal pain, ultrasound, appendicitis DOI: 10.1594/ecr2010/C-1660 Any information contained in this pdf file is automatically generated from digital material submitted to EPOS by third parties in the form of scientific presentations. References to any names, marks, products, or services of third parties or hypertext links to third- party sites or information are provided solely as a convenience to you and do not in any way constitute or imply ECR's endorsement, sponsorship or recommendation of the third party, information, product or service. ECR is not responsible for the content of these pages and does not make any representations regarding the content or accuracy of material in this file. As per copyright regulations, any unauthorised use of the material or parts thereof as well as commercial reproduction or multiple distribution by any traditional or electronically based reproduction/publication method ist strictly prohibited. You agree to defend, indemnify, and hold ECR harmless from and against any and all claims, damages, costs, and expenses, including attorneys' fees, arising from or related to your use of these pages. Please note: Links to movies, ppt slideshows and any other multimedia files are not available in the pdf version of presentations. www.myESR.org Page 1 of 41 Learning objectives To list the spectrum of main pathologic processes that can cause acute right lower quadrant abdominal pain.
    [Show full text]
  • MAY 2015 UCCOP Has a Watchful Eye
    ™ MAY 2015 VOLUME 9, NUMBER 8 THE JOURNAL OF URGENT CARE MEDICINE® www.jucm.com The Official Publication of the UCAOA and UCCOP PUBLICATION BRAVEHEART A has a watchful eye. a 4FFGPSZPVSTFMG WJTJUOITJODDPN nhsinc.com The Art of the Right Fit™ LETTER FROM THE EDITOR-IN-CHIEF “Why Are You Calling Me?” How to Fix Relationships with Emergency Departments n my last column I covered the 3 main understood, mutual goal-setting and prioritization can com- Icauses of poor communication in transfer- mence, and it is invariably productive and helpful. ring patients from urgent care centers to emergency departments (EDs). I discussed Step 3: Policy and Procedure Development how poor communication creates risk, dis- Once the two parties are aligned, policy and procedure can be rupts work flow, and erodes professional sat- developed to help guide the clinical teams in both settings. The isfaction. Poor interprofessional relationships and inadequate goals of this exercise should be to facilitate transfers, keep com- planning and structure are creating an environment ripe for these munication focused and relevant, reduce interruptions, and breakdowns. Reversing the trend requires a focus on rehabilitat- eradicate judgmental or insulting commentary. Each medical ing relationships, initiating outreach, and developing coordinated director should commit to clearly communicating the new poli- policies and procedures for transfers and communication. cies and procedures to all of their physicians and, importantly, to all members of the nursing staff. A culture of mutual under- Step 1: Breaking the Ice standing and respect should be expected and clearly communi- As with all functional relationships, getting to know the people cated to everyone involved.
    [Show full text]
  • Epiploic Appendagitis Masquerading As Pulmonary Embolism
    View metadata, citation and similar papers at core.ac.uk brought to you by CORE provided by Elsevier - Publisher Connector CMIG Extra: Cases 28 (2004) 1–3 www.elsevier.com/locate/compmedimag Case report Epiploic appendagitis masquerading as pulmonary embolism V. Sites, C. Wald*, F. Scholz Department of Diagnostic Radiology, Lahey Clinic Medical Center, Burlington, MA 01805, USA Received 13 February 2003; accepted 6 August 2003 Abstract There has been recent interest in the radiological literature regarding the various clinical manifestations of epiploic appendagitis, which may mimic many acute abdominal and pelvic conditions. We present a case of appendagitis masquerading as pulmonary embolism; to our knowledge the first reported such presentation with primary thoracic symptoms and findings prompting an initial workup for suspected pulmonary thrombembolism. Radiographic findings, differential diagnosis and the pertinent literature are briefly discussed. q 2003 Elsevier Ltd. All rights reserved. Keywords: Epiploic appendagitis; Atelectasis; Pulmonary thrombembolism 1. Introduction the proximal descending colon. A water-soluble contrast enema revealed no abnormality. An abdominal CT scan There has been recent interest in the radiological demonstrated a left pleural effusion and basal atelectasis literature regarding the abdominal manifestations of epi- (Fig. 1). A lung scan was low probability for pulmonary ploic appendagitis. The most common clinical manifes- embolus. A bilateral lower leg extremity ultrasound was tation is lower abdominal pain simulating diverticulitis, negative. Review of the CT scan showed inflammatory appendicitis and gynecologic disease in women. Since change in the fat of the left upper quadrant adjacent to the epiploic appendages are distributed throughout the colon, left hemidiaphragm and a small focus of oval fat surrounded upper abdominal symptoms are possible.
    [Show full text]
  • Epiploic Appendagitis
    Central JSM Clinical Case Reports Clinical Image *Corresponding author Corina Ungureanu, General Internal Medicine OSU Care Point East, 543 Taylor Avenue, Columbus, Ohio Epiploic Appendagitis: An 43203, Ohio State University, USA; Tel: 614-688-6470; Fax: 614-688-6471; E-mail: [email protected] Submitted: 06 November 2013 Uncommon Cause of Abdominal Accepted: 18 January 2014 Published: 21 January 2014 Pain Copyright © 2014 Ungureanu et al. Michael Langan, Veronica Marcantoni and Corina Ungureanu* Department of Internal Medicine, Ohio State University, USA OPEN ACCESS CLINICAL IMAGE Epiploic appendages are fat filled sacs extending from the serosal surface of the colon into the peritoneum. There are approximately 100 appendices along the length of the colon, with most clustering in the cecal and sigmoid region [1,2]. Epiploic appendagitis occurs when epiploic appendages undergo torsion or have spontaneous thrombosis of the draining veins and subsequently become infarcted [1,2,3]. Presentation can be seen at any age but is most common in the second to fifth decades of life [3]. A 34 year old male presented to the emergency room with a three day history of left lower quadrant abdominal pain. The pain was sudden in onset, sharp, stabbing and pressure-like in character with an intensity of 8/10. Associated symptoms Figure 2 included nausea and lightheadedness. It worsened with food consumption and external pressure. There were no alleviating Coronal view of abdominal CT scan showing inflamed appendage (circled). factors. He denied fever, chills, bloating, constipation, diarrhea, melena, hematochezia, dysuria, or hematuria. He had no previous history of nephrolithiasis, colon cancer or diverticulitis.
    [Show full text]
  • Epiploic Appendagitis
    RHODE ISLAND M EDICAL J OURNAL MEDICAL SCHOOL GRADUatION PAGE 47 DR. ELLENBOGEN ON CONCUSSIONS: THE PERFECT STORM PAGE 43 DR. DAILEY CHAIRS HEALTH COMMISSION paGE 57 SPECIAL SECTION BROWN SCHOOL of PUBLIC HEALTH JUNE 2013 VOLUME 96 • NUMBER 6 ISSN 2327-2228 Some things have changed in 25 years. Some things have not. Since 1988, physicians have trusted us to understand their professional liability, property, and personal insurance needs. Working with multiple insurers allows us to offer you choice and the convenience of one-stop shopping. Call us. rims I B C 800-559-6711 RIMS-INSURANCE BROKERAGE CORPORATION Medical/Professional Liability Property/Casualty Life/Health/Disability RHODE ISLAND M EDICAL J OURNAL 20 BROWN SCHOOL OF PUBLIC HEALTH KRIS CAMBRA, MA; TERRIE FOX WETLE, PhD GUEST EDITORS 23 Educational Opportunities in Clinical and Translational Research PATRICK VIVIER, MD, PhD 25 The Sum is Greater than its Parts: The Center for Evidence-Based Medicine KRIS CAMBRA, MA; THOMAS A. TRIKALINOS, MD, PhD; EILEEn O’GaRA-KUrtIS 27 Creating the Future: Brown University’s Executive Master of Healthcare Leadership ELIZABETH A. KOFRON, PHD 29 Joan Teno, MD: Leader in Crusade for Quality Hospice, Palliative Care MARY KORR, RIMJ MANAGING EDITOR 31 Kahler’s Research Bridges Behavioral/Social Sciences and Medical Care MARY KORR, RIMJ MANAGING EDITOR RHODE ISLAND M EDICAL J OURNAL 8 COMMENTARY Establishing a Legacy: The Aronson Chair for Neurodegenerative Disorders JOSEPH H. FRIEDMAN, MD Pilgrimage of an Herb Named Foxglove STANLEY M. ARONSON, MD 14 GUEST COMMENtaRY ‘The doing of medicine, the being of a doctor’ JONATHAN A.
    [Show full text]
  • Asymptomatic Epiploic Appendage with Torsion in Laparoscopic Surgery: a Case Report and Literature Review
    8390 Case Report Asymptomatic epiploic appendage with torsion in laparoscopic surgery: a case report and literature review Peiming Sun1^, Jianwu Yang1^, Hongchang Ren1, Xiaobo Zhao2, Hongwei Sun1^, Jie Cui1, Heming Yang1^, Yan Cui1^ 1Department of General Surgery, Strategic Support Force Medical Center, Beijing, China; 2Department of Pathology, Strategic Support Force Medical Center, Beijing, China Correspondence to: Hongwei Sun, MD, PhD; Heming Yang, MD, PhD. Department of General Surgery, Strategic Support Force Medical Center, 9 Anxiangbeili, Chaoyang District, Beijing 100101, China. Email: [email protected]; [email protected]. Abstract: Torsion of an epiploic appendage may result in epiploic appendagitis, which is a rare cause of acute abdominal pain. However, no previous reports have described an asymptomatic twisted epiploic appendage found during laparoscopic surgery to the best of our knowledge. This case describes a 66-year-old man who was admitted to our medical center with yellowness of the skin and eyes that had lasted over two months. Physical examination showed slight yellow staining of the skin and sclera. Blood analysis indicated liver dysfunction and jaundice. Routine blood, C-reactive protein (CRP), and levels of tumor markers were normal. The contrast-enhanced abdominal and pelvic computed tomography, magnetic resonance imaging, and magnetic resonance cholangiopancreatography revealed gallbladder atrophy and choledocholithiasis. The patient underwent laparoscopic surgery for the removal of the choledocholithiasis. The laparoscopic exploration unexpectedly revealed a twisted and ischemic epiploic appendage, which was surgically removed. The postoperative pathological examination uncovered necrosis of adipocytes and vascular obstruction, but there was no inflammation of the epiploic appendage. The patient had a satisfactory recovery during the 16-month follow-up period.
    [Show full text]
  • Epiploic Appendagitis Masquerading As Acute Appendicitis: a Report of Two Cases
    Open Access Case Report DOI: 10.7759/cureus.10689 Epiploic Appendagitis Masquerading as Acute Appendicitis: A Report of Two Cases Aaliya F. Uddin 1 , Gautam Menon 2 , Arathi Menon 3 , Abdalla Saad Abdalla Al-Zawi 4, 5, 6 , Jay Menon 7 1. General Surgery, Basildon and Thurrock University Hospital, Basildon, GBR 2. Acute Medicine, Mid and South Essex NHS Foundation Trust, Chelmsford, GBR 3. Radiology, Royal Free Hospital, London, GBR 4. Breast Surgery, Anglia Ruskin University, Chelmsford, GBR 5. Breast Surgery, Basildon and Thurrock University Hospital, Basildon, GBR 6. General Surgery, Mid and South Essex NHS Foundation Trust, Basildon, GBR 7. Vascular Surgery, Basildon and Thurrock University Hospital, Basildon, GBR Corresponding author: Aaliya F. Uddin, [email protected] Abstract Epiploic appendagitis (EA) is a rare clinical entity caused by an inflammatory/ischemic process involving the serosal outpouchings of the colon. Its clinical presentation of acute, localised, lower abdominal pain often mimics more common conditions like diverticulitis or appendicitis. The diagnosis of EA is challenging due to the lack of pathognomic clinical features. The definitive diagnosis primarily relies on cross-sectional imaging modalities like abdominal ultrasound or computed tomography (CT). Being a benign and self- limiting condition, it can be managed conservatively with analgesic and anti-inflammatory drugs. We present two cases to highlight EA as an important differential diagnosis for cases of acute lower abdominal pain, crucial to prevent unnecessary antibiotic therapy and surgical interventions. Categories: General Surgery Keywords: appendicitis, epiploic appendagitis, diagnostic laparoscopy, acute abdominal pain Introduction Epiploic appendagitis (EA) is a benign, mostly self-limiting, inflammatory/ischemic disorder of the epiploic appendages, which are fat-filled serosal outpouchings of the colon.
    [Show full text]
  • Epiploic Appendagitis: an Often-Unrecognized Cause of Acute Abdominal Pain
    IMAGES IN MEDICINE Epiploic Appendagitis: An often-unrecognized cause of acute abdominal pain LINDA RATANAPRASATPORN, LISA RATANAPRASATPORN, TERRANCE HEALEY, MD causes of acute abdominal pain, such as acute appendicitis or diverticulitis. Before the advent of CT imaging, EA was most commonly diagnosed at surgery. In 1986, Danielson et al2 described the CT findings. The use of emergency abdominal CT scan can aid in the diagnosis of EA and its differ- entiation from other causes of lower quadrant abdominal pain in order to avoid unnecessary an- tibiotics, hospital admission, and surgical interven- tion. Here we review the significant signs, symp- toms, radiologic findings, and treatment of EA. Epiploic appendages are fatty pedicular struc- tures found on the serosal surface of the normal co- lon. Each person has an estimated 50-100 epiploic appendages, most commonly found on the sigmoid Figure 1. Axial CT scan without contrast shows an oval shaped epiploic appendage colon and cecum. Although usually 3 cm in length, 3 with stranding of the adjacent mesentery (arrow) diagnostic of epiploic appendagitis, some can be up to 15 cm long. The function of a non-surgical cause of abdominal pain. epiploic appendages is not known. Symptomatic EA can occur in any part of the CASE colon and most commonly presents in adult males and fe- A 54-year-old woman presented to her primary care phy- males in their second to fifth decade.4 EA is thought to be sician with acute left lower quadrant abdominal pain. She more common in obese patients and those with recent sig- had no fever or chills but did have nausea for several hours.
    [Show full text]
  • 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.
    [Show full text]
  • 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.
    [Show full text]
  • Acute Abdomen Due to Epiploic Appendagitis
    LETTER TO THE EDITOR ASIAN JOURNAL OF MEDICAL SCIENCES Acute abdomen due to epiploic appendagitis Submitted: 18-04-2019 Revised: 22-04-2019 Published: 01-05-2019 Access this article online Dear Editor, Website: http://nepjol.info/index.php/AJMS As you are aware, epiploic appendagitis is a rare cause DOI: 10.3126/ajms.v10i3.23656 of acute abdomen, and can mimic other pathologies for E-ISSN: 2091-0576 abdominal pain. It results from torsion and inflammation P-ISSN: 2467-9100 of an epiploic appendix, thereby leading to localized abdominal pain. Due to its vague presentation, the diagnosis can often be challenging. Epiploic appendagitis refers to inflammation of one or more of the appendices epiploicae, which are small, A 24 year old male, with no known comorbidities, presented serosa-covered fat pads attached to the outer surface of to Medicine department with severe left lower abdominal pain the colonic wall, measuring from 0.5 cm to 5 cm in length since morning. The pain was acute on onset and progressive and 1 to 2 cm in width. There are nearly 100 appendages with no other associated symptoms. On abdominal palpation, scattered throughout the peritoneal cavity.1,2 They are he had severe left iliac tenderness with no radiation. His distributed along the rectosigmoid junction (57%), ileocecal vitals and other systemic examinations were normal. His region (26%), ascending colon (9%), transverse colon (6%) blood investigations like complete blood counts, renal and and descending colon (2%).3-5 The condition can occur liver functions, electrolytes and calcium were normal. Urine at any age, with incidence being slightly higher in males.6 microscopy did not show any pus cells.
    [Show full text]
  • Primary Epiploic Appendagitis
    Gupta et al. Clin Med Rev Case Rep 2016, 3:110 Volume 3 | Issue 6 Clinical Medical Reviews ISSN: 2378-3656 and Case Reports Case Report: Open Access Primary Epiploic Appendagitis Neha Gupta*, Tony A AbdelMaseeh, Leyden Standish-Parkin and Yekaterina Sitnitskaya Departments of Pediatrics, Lincoln Medical Center, Bronx, NY, USA *Corresponding author: Neha Gupta, Department of Pediatrics, Lincoln Medical Center, 234 E 149th street, Bronx, New York 10451, Tel: 347-500-6980, E-mail: [email protected] mimic acute appendicitis or diverticulitis, depending on its location. Abstract Here we present a teenager with right lower quadrant (RLQ) Epiploic appendagitis is a rare diagnosis in pediatric population. abdominal pain who was diagnosed with epiploic appendagitis by It is a benign, self-limiting condition caused by infarction, torsion computed tomography (CT) scan. or thrombosis of the fatty appendages on the serosal surface of the colon. It can be a diagnostic dilemma as it can mimic acute Case appendicitis or diverticulitis, depending on its location. We report a case of a teenage girl who presented with right lower quadrant A 16-year-old sexually active female with a history of migraine abdominal pain without any associated vomiting, fever, and headaches presented with 3 days of RLQ abdominal pain (7/10), improved diarrhea. Laboratory work up was non-contributory. Computed with Ibuprofen and with no associated symptoms like anorexia, nausea, tomography of the abdomen helped in the diagnosis of epiploic vomiting, changes in bowel or urinary habit, or vaginal discharge. Her appendagitis. She was successfully treated with non-steroidal anti- last menstrual period started the same day as the RLQ pain.
    [Show full text]