We present the case of a 33 year old male who presented with a one day history of non-radiating right upper quadrant abdominal pain worsened by physical activity and lying on his right side. The patient initially suspected that he may have been constipated, but then presented to our hospital due to increasing intensity of his symptoms. He denied subjective fevers or chills, and was found to be afebrile upon presentation. Physical exam was benign with the exception of tenderness to palpation in the right upper quadrant. A CT study of the abdomen and pelvis was performed which noted marked inflammatory changes in the mesenteric fat along the right colon correlating to the area of tenderness. Laboratory studies revealed leukocytosis of 15,300 cells/mcL. The resident surgical team initially evaluated the patient and tentatively diagnosed the patient with either a phlegmon or right-sided diverticulitis, so they recommended the patient be admitted by the resident medicine team for intravenous antibiotics, pain control, and serial abdominal examinations. On review of the final radiology report of the CT abdomen and pelvis, the patient was diagnosed with epiploic appendagitis. By the next day, the patient reported that his abdominal pain had almost completely resolved, and he was discharged home that day.
Primary epiploic appendagitis is a benign and self-limiting condition characterized by abdominal pain secondary to ischemic infarction of one or more epiploic appendages along the external colon. This condition is most commonly diagnosed by radiologic findings. Leukocytosis is not typically associated with epiploic appendagitis. 12.9% of patients in one report (Choi et al.) were found to have leukocytosis on laboratory studies, while another study reported leukocytosis in 33% of patients diagnosed with primary epiploic appendagitis (Ozdemir et al.). While imaging studies may lead clinicians towards the diagnosis, our case illustrates that the presence of leukocytosis is uncommonly associated findings that may confound the clinicians’ differential diagnosis, thereby leading to misdiagnosis and over-treatment of the condition.
Given the unfamiliarity and relative infrequency of this condition, epiploic appendagitis is often underdiagnosed by clinicians. Thus, it is useful to keep on one’s differential when deciding whether or not to admit a patient. The presence of leukocytosis can further confound the diagnosis. Misdiagnosis of this condition often results in unnecessary antibiotic use and even surgical intervention.
Choi, Y, PW Choi, YH Park, JI Kim, TG Heo, JH Park, MS Lee, CN Kim, SH Chang, and JW Seo. Clinical characteristics of primary epiploic appendagitis. Journal of the Korean Society of Coloproctology (2011): 114-21.
Ozdemir, Suleyman, K Gulpinar, S Leventoglu, E Turkoz, HY Uslu, N Ozcay, and A Korkmaz. Torsion of the primary epiploic appendagitis: A Case Series and Review of the Literature. The American Journal of Surgery (2010): 453-58.