Primary epiploic appendagitis: CT manifestations

Inflammation of an epiploic appendage is considered to be a rare cause of acute abdomen. Recently, it has been reported that typical computed tomography (CT) findings of primary epiploic appendagitis (PEA) provide a definitive diagnosis in most of the cases. However, since these papers are only few, they are easily overlooked by the practicing radiologists. Our purpose is to add four new cases to the existing literature and to perform a review of the literature.     

Acute epiploic appendagitis: CT findings in 33 cases

Acute epiploic appendagitis (AEA) is a benign self-limiting process presenting with acute abdominal pain often misdiagnosed clinically as either diverticulitis or appendicitis, but which has a pathognomonic CT appearance. The CT findings in 33 adult patients diagnosed by CT over a 33-month period as having AEA were retrospectively reviewed. The study group included 24 men and 9 women, with a mean age of 44.6 years. The mean age of the male patients was lower than that of the female patients, 40.9 vs 54.7 years. All patients presented with acute abdominal pain, mainly in the left (n=21) and right (n=9) lower quadrants, with localized tenderness in all patients and peritoneal irritation in 15 of them. Low-grade fever was found in 8 patients and mild leukocytosis in 16. Characteristic CT findings of an oval fatty mass with central streaky densities and surrounded by mesenteric stranding adjacent to the serosal surface of the colon were seen in all cases. Additional findings included mural thickening of the juxtaposed colon in 16 patients and peritoneal fluid in 7. One patient underwent surgery on the basis of an erroneous diagnosis of acute appendicitis. As CT is often used nowadays to evaluate various acute abdominal complaints, it may be the first imaging modality by which AEA is diagnosed. AEA should be included in the differential diagnosis in young male patients with localized left lower abdominal pain and tenderness. Electronic Publication     

Multidetector computed tomography diagnosis of primary and secondary epiploic appendagitis

Purpose  The aim of this study was to evaluate the epiploic appendages in patients with acute abdomen using multidetector computed tomography (MDCT) and to determine the incidence of primary and secondary epiploic appendagitis (EA). Materials and methods  A radiologist reviewed MDCT images from 1338 patients with acute abdomen for visible epiploic appendages. Two radiologists then reviewed the MDCT images showing inflamed epiploic appendages and diagnosed primary EA, secondary EA, or other conditions by consensus. The CT criteria for primary EA are a round or oval pericolonic fatty lesion with a hyperattenuated rim and adjacent fat stranding, without other causes of inflammation. Secondary EA is diagnosed if an epiploic appendage is found to be due to inflammation from other inflammatory entities. Results  Epiploic appendages were identified in 19 patients. Four patients (0.3%) had a retrospective CT diagnosis of primary EA. Twelve patients (0.9%) had a retrospective CT diagnosis of secondary EA (primary condition was diverticulitis in 10 patients and inflammatory bowel disease in 2 patients). The remaining three patients had calcification of an epiploic appendage suggestive of old EA. Conclusion  Primary EA should be included in the differential diagnosis of acute abdomen. Occasionally, inflammation of the epiploic appendages is secondary to other inflammatory conditions.     

Acute epiploic appendagitis in hernia sac: CT appearance

We describe an unusual cause of acute abdomen due to acute epiploic appendagitis located within an incisional hernia sac. The contrast-enhanced CT showed an oval fat density structure with surrounding inflammation in the transverse mesocolon. The contrast-enhanced CT findings of the inflammation of appendices epiploicae of the transverse colon were diagnostic in this case.     

Primary epiploic appendagitis: US and CT findings

A retrospective review is presented of seven cases of epiploic appendagitis, with surgical confirmation in one case. The main clinico-analytical data and the US and CT findings are described, as well as the histopathologic features in the sole case that underwent surgical resection. We also calculated the frequency of this entity in patients undergoing emergency abdominal US on clinical suspicion of diverticulitis. In all seven cases the clinico-analytical evidence was nonspecific (localized acute abdominal pain and slight leukocytosis), mimicking in six cases the clinical presentation of sigmoid diverticulitis and in one case that of acute appendicitis. US imaging findings were characteristic: a hyperechoic mass localized under the point of maximum pain, adjacent to the anterior peritoneal wall and fixed during deep breathing. In none of the cases did color Doppler US show flow. CT findings were also typical and showed a mass with a peripheral hyperattenuated rim surrounding an area of fatty attenuation. Overall 7.1 % of patients investigated to exclude sigmoid diverticulitis finally showed findings of primary epiploic appendagitis. Primary epiploic appendagitis thus shows characteristic US and CT findings that allow its diagnosis and follow-up. This entity is much more frequent than previously reported, especially in patients referred for US to exclude sigmoid diverticulitis. Received: 1 April 1997; Revision received 19 August 1997; Accepted 2 September 1997     

Right lower quadrant pain: Imaging with computed tomography

Computed tomography (CT) is a fast and accurate way to evaluate patients with acute right lower abdominopelvic pain. In the emergency setting, appendicitis is the most common etiology. A tailored CT examination can visualize the normal or abnormal appendix with accuracy, confirming or excluding appendicitis in 90–95% of cases. If the appendix is normal, CT often identifies an alternative etiology for the pain. This exhibit reviews the CT appearance of the normal appendix, usual and unusual presentations of appendicitis and complicated appendicitis, and pitfalls in diagnosis. The CT appearance of other conditions included in the differential diagnosis of acute right lower quadrant pain and clinically mimicking appendicitis is also presented, including disorders arising from the gastrointestinal tract, genitourinary tract, and vascular and musculoskeletal systems.     

MSCT对原发性肠脂垂炎的检查价值

目的 探讨原发性肠脂垂炎（PEA）的CT特征,MSCT的检查价值.方法 对12例具有完整MSCT扫描资料并随访证实的原发性肠脂垂炎病例进行回顾性分析.12例均行全腹平扫,其中2例行增强扫描.结果 10例病灶位于直乙状结肠转折处,1例位于回盲部,1例位于降结肠;12例卵圆形脂肪密度病灶均可见边缘高密度环,11例病灶中心可见高密度影;9例病灶周围可见继发性炎性改变,其中5例可见邻近腹膜增厚,但均未见邻近肠壁增厚及周围积液;2例增强扫描病灶边缘的高密度环及邻近增厚的腹膜可见强化.4～10周后CT随访,12例病灶均自行消退.结论 边缘高密度环征、中心高密度影和周围继发性炎性改变为原发性肠脂垂炎的特征性CT表现,MSCT能清楚显示病灶细节特征及毗邻结构,对原发性肠脂垂炎的诊断有决定性意义.     

原发性肠脂垂炎的CT表现及临床意义

目的 分析原发性肠脂垂炎（PEA）的CT特点及临床应用价值.方法 回顾性分析2008年5月～2013年7月经诊断为PEA的完整资料.主要分析肿块的部位、大小、形态、密度及周围情况.结果 肿块位于乙状结肠旁10例,回盲部旁6例,升结肠旁2例,降结肠旁2例,结肠肝曲旁1例.肿块呈圆形、椭圆形.肿块大小1.0cm×1.1cm～2.8cm×3.2cm,平均2.1cm×2.4cm.CT表现早期3例,脂肪肿块内有云絮状高密度,边缘较薄环壁,增强后环壁轻度强化,肿块内絮状、条索状强化.进展期12例,肿块内高低混杂密度,环壁较厚,边缘清楚,环壁中等强化.恢复期6例,肿块缩小,形态不规则,壁变薄,环壁轻度强化.12例进展期中,周围系膜肿胀12例,附近结肠壁轻度增厚5例,小肠袢受压2例,周围淋巴结肿大4例.21例PEA中,9例经手术病理证实,12例影像学检查,并随访病变缩小或消失.结论 CT对PEA的定性诊断有重要价值,对指导临床治疗有重要意义.     

Imaging right lower quadrant pain: Not always appendicitis

Although acute appendicitis (AA) is one of the commonest causes of right lower quadrant abdominal pain (RLQP), there are numerous other conditions in the abdomen and pelvis that can simulate the clinical presentation of AA for which imaging is essential in detection. We discuss the approach to evaluation of patients presenting with acute onset RLQP and the choice of various imaging modalities that can be utilized. Although CT remains the workhorse in evaluation, US and MRI, given lack of radiation, play an important ancillary role, particularly in the pediatric and pregnant patients. We present a spectrum of conditions presenting with RLQP which we have classified systematically ranging from conditions affecting the bowel, mesentery/omentum/peritoneum, vasculature, urinary and reproductive systems to give the reader a checklist of conditions to consider when evaluating a case of RLQP.     

超声与CT诊断原发性肠脂垂炎的比较

目的:分析原发性肠脂垂炎(PEA)的超声和CT影像特点,比较两者的诊断价值。方法:36例PEA中,男30例,女6例。所有病例均行超声和CT检查,比较两者诊断符合率。结果:PEA超声特点表现为结肠壁旁卵圆形、不可压缩的高回声团块,且与腹壁有粘连;CT特征表现为结肠壁旁"戒指"样或卵圆形脂肪性密度。超声诊断PEA符合率为88.9%,CT诊断符合率为91.7%,两者差异无统计学意义(2=0.06,P>0.10)。结论:超声诊断PEA是首选影像学检查手段,CT可作为补充。     

Right lower quadrant pain and suspected appendicitis: nonfocused appendiceal CT--review of 100 cases

PURPOSE: To determine the value of standard, nonfocused computed tomography (CT) in examining patients with right lower quadrant (RLQ) pain and suspected appendicitis. MATERIALS AND METHODS: The CT scans and medical records of 100 consecutive patients who presented to the emergency department with RLQ pain and were clinically suspected of having appendicitis were retrospectively reviewed. Helical CT of both the abdomen and pelvis was performed at 7-mm increments after oral and intravenous contrast material administration. CT scans were evaluated for the presence of appendiceal or other disease. Results were correlated with surgical and pathologic findings in 34 patients or with 3-month clinical follow-up in 66 patients. RESULTS: CT depicted abnormalities in 66 patients (66%). In 59 (59%) patients, the abnormality was located in the pelvis; 23 (39%) of these patients had appendicitis. Seven (7%) patients had abnormalities outside of the pelvis, a region not typically scanned during focused appendiceal imaging. Four of these seven patients required surgery. Thus, if only pelvic focused RLQ CT had been performed, overall sensitivity would have decreased from 99% to 88% (P <.05) and sensitivity for cases necessitating surgery would have decreased from 96% to 82% (P <.05). CONCLUSION: Both abdominal and pelvic CT examinations are necessary to increase sensitivity and identify the many possible causes of RLQ pain in patients with clinically suspected appendicitis.     

Right lower quadrant pain: value of the nonvisualized appendix in patients at multidetector CT

PURPOSE: To retrospectively determine the value of the nonvisualized appendix at multidetector computed tomography (CT) in patients with acute right lower quadrant pain in whom appendicitis was a consideration. MATERIALS AND METHODS: Institutional review board approval was obtained for this HIPAA-compliant study, with waiver of informed consent. Records were retrospectively reviewed in patients who presented to the emergency department between April 29 and October 31, 2003, with right lower quadrant pain. Scanning was performed with the same eight-detector row CT scanner by using oral and (unless contraindicated) intravenous contrast agents, and transverse and coronal reformations were obtained. Two radiologists prospectively evaluated all scans at the time of the examination and rendered a consensus opinion. Clinical follow-up of at least 3 months' duration was performed retrospectively for patients whose appendix was not visualized to determine whether appendicitis had developed. Statistical analysis and calculation of percentages with confidence intervals (CIs) were performed. RESULTS: Of the 400 consecutive patients who underwent multidetector CT, 132 (33.0%) were male and 268 (67.0%) were female. Eighty patients (20.0%) had acute appendicitis and 79 (19.8%) had another cause for abdominal pain. A normal appendix with no other cause for pain was seen in 182 patients (45.5%). In 59 patients (14.8%), the appendix was not visualized. Of these 59 patients, 50 had adequate follow-up. Clinical follow-up was uneventful in 49 of these 50 patients. Thus, on otherwise normal multidetector CT scans in patients suspected of having acute appendicitis, nonvisualization of the appendix was negative for appendicitis in 98% (95% CI: 71%, 100%) of cases. Conversely, when the appendix was seen at multidetector CT and was abnormal, appendicitis was present in 95% (95% CI: 72%, 100%) of cases. CONCLUSION: In patients with right lower quadrant pain, a nonvisualized appendix at multidetector CT reliably excludes acute appendicitis.     

Helical CT evaluation of acute right lower quadrant pain: part I, common mimics of appendicitis

OBJECTIVE: The purpose of our pictorial essay is to present common mimics of appendicitis as noted on helical CT in patients with right lower quadrant pain and to highlight the features that provide clues to the diagnosis. CONCLUSION: Recognition of the findings of common diseases that simulate acute appendicitis on helical CT, along with features that help to differentiate these entities from appendicitis, is important in establishing a correct diagnosis and in guiding appropriate therapy.     

Helical CT evaluation of acute right lower quadrant pain: part II, uncommon mimics of appendicitis

OBJECTIVE: The purpose of our pictorial essay is to highlight the helical CT features of uncommon mimics of appendicitis and to provide clues to differentiate them from appendicitis. CONCLUSION: Uncommon mimics of appendicitis create a diagnostic challenge in patients with right lower quadrant pain. Recognition of the helical CT features of uncommon mimics of appendicitis is important in clinical management and avoiding unnecessary laparotomy.     

Acute right lower quadrant pain beyond acute appendicitis: MDCT in evaluation of benign and malignant gastrointestinal causes

Purpose

To evaluate the role of MDCT in identification of various GIT pathologies beyond appendicitis that cause acute right lower quadrant abdominal pain and characterization of various distinguishing CT features as well as their predictive values in differentiating benign from malignant pathologies.

Materials and methods

This retrospective study included a total of 64 patients (34 females and 30 males with age ranges from 21 to 78 years) who presented with ARLQP (acute right lower quadrant pain). MDCT was done for all the patients; inclusion criteria included the presence of clinical, laboratory, and radiological evidence of the pathologic process. Pathological confirmation was obtained in 44 cases. All cases proved pathologically to be appendicitis were eventually excluded from the study cohort. Various CT morphologic parameters were recorded including the location of bowel wall involvement, the extent of involvement, the thickness of bowel wall and pattern of bowel wall thickening, the presence of stratified enhancement pattern, the transition from normal to abnormal wall, the degree of mesenteric fat stranding relative to the degree of wall thickening, the presence of excavating masses, and associated findings. A multivariate analysis was performed using covariates among the variable morphologic CT features.

Results

A stratified enhancement pattern of the bowel wall was the most reliable to indicate a benign active inflammatory process with the highest −ve predictive value of 91% and an abrupt zone of transition also proved to be the most significant in indicating a malignant process with a +ve PV of 74%.

Conclusion

Using a systematic pattern approach MDCT has proved to be an extremely useful noninvasive method for evaluation of patients with acute RLQP, allowing diagnosis and management of not only the most common conditions such as appendicitis but also less common conditions.     

CT导引腹腔神经丛阻滞治疗上腹部顽固性癌性疼痛的研究

目的 评价腹腔神经丛阻滞的止痛疗效,分析影响止痛效果的因素。方法 ４２例由胰腺癌,肝癌,胃癌,结肠癌,胆管癌引起的顽固性上腹痛或伴有牵涉性背痛的患者经ＣＴ导引两侧腹腔神经丛酒精阻滞,止痛效果被分为０－Ⅲ级,并通过工作站三维重建对比剂扩散情况。结果 经３个月随访观察,在２周,１个月,２个月,３个月,止痛总有效率分别为９２．８６％,８８．１０％,８５．００％,８０．５６％。     

肝细胞癌扩散至右肾上腺的CT表现及其解剖学基础

目的分析肝细胞癌(HCC)扩散至右肾上腺的CT增强表现特征，探讨扩散的途径和解剖学基础，为临床提供全面的影像学信息，帮助选择治疗方案。资料与方法经临床、病理证实的HCC连续性病例中，回顾性分析肿瘤扩散至右肾上腺患者39例，另选择临床确诊为HCC，但右肾上腺形态、密度无异常者5例作为对照组。全部病例均采用螺旋CT动、门脉双期增强扫描。重点观察病灶部位、大小、密度，肝裸区是否受侵犯，肝内病灶与右肾上腺之间的毗邻关系，右肾上腺形态、轮廓、密度，右肾上腺区域有无软组织密度肿块及其强化特征。结果39例肝内病灶经裸区侵犯右肾上腺，其中10例右肾上腺区未形成软组织肿块，但右肾上腺与肝内肿块分界不清、正常轮廓消失，动脉期其密度低于左肾上腺，门静脉期密度不均匀；29例右肾上腺区见软组织肿块或结节且与肝内肿块分界不清，右肾上腺正常轮廓消失或完全被肿块包埋。右肾上腺区肿块，CT增强扫描动脉期呈不均匀明显强化或轻度强化，门脉期密度降低，其强化时相及特征与肝内原发病灶一致。结论HCC可通过肝裸区直接侵犯右肾上腺。根据CT增强动、门脉双期扫描右肾上腺形态、密度有无异常及右肾上腺区软组织肿块密度、强化时相和特征，可判断HCC是否扩散至右肾上腺。     

糖尿病患者下肢动脉病变血管造影表现及介入治疗的近期疗效观察

目的 探讨糖尿病患者下肢动脉病变血管造影表现及介入治疗的近期临床疗效.方法 回顾性分析38例(44条患肢)糖尿病患者下肢动脉病变血管造影表现及介入治疗后1周,1、3、6、12个月的临床表现、体征及踝-肱指数(ABI)的变化和治疗效果.临床疗效评估分为显效、有效、无效和恶化4个等级.有效率=(显效+有效)/总例数×100%.ABI结果的比较采用方差分析.结果 血管造影显示,糖尿病患者下肢动脉病变为多支病变,呈多节段、广泛性狭窄或闭塞.25条(56.8%,25/44)患肢膝上和膝下动脉均有病变;1条(2.3%,1/44)患肢单纯膝下1支动脉病变;6条(13.6%,6/44)患肢2支动脉病变;9条(20.5%,9/44)患肢3支动脉病变;3条(6.8%,3/44)患肢单纯膝上动脉病变.膝下动脉经皮腔内血管成形术(PTA)技术成功率为91.4%(53/58).12例足踝部溃疡患者3个月内愈合9例,6个月内踝下截肢1例,膝下截肢2例;4例坏疽患者1个月内膝下截肢,截肢率15.9%(7/44).介入综合治疗后1周,1、3、6和12个月的有效率分别为79.6%(35/44)、83.3%(30/36)、85.7%(24/28)、85.0%(17/20)和81.3%(13/16);ABI值分别为0.86±0.10、0.85±0.10、0.83±0.11、0.79±0.12和0.75±0.12,较术前0.53±0.20明显升高(F=35.79,P＜0.05),但术后6个月ABI值开始出现下降趋势.结论 糖尿病患者下肢动脉病变以膝下动脉病变合并膝上动脉病变最为常见,介入治疗能有效改善患者下肢动脉缺血的症状和体征,短期随访临床疗效满意.     

Mandibular fracture not shown by axial computed tomography: Benefit of computed reformation

A 36-year-old man was brought to the emergency department after being assaulted. A mandible series showed a nondisplaced fracture through the angle of the mandible extending through the left third molar tooth. Axial slices from a nonhelical computed tomographic (CT) examination of the head as well as a helical CT examination of the mandible failed to demonstrate the fracture. The fracture was well shown, however, on sagittal CT reformations. Although CT is generally regarded as more sensitive than plain radiography for the detection of fractures, fractures may be overlooked by CT if examination in only one plane is performed.