Torted caecal appendix epiploica mimicking acute appendicitis in childhood
Jackson CR, Hosie GP
Author for correspondence:
Mrs CR Jackson
Royal Hospital for Sick Children
Sciennes Road
Edinburgh
EH9 1LF
Tel: 0131 536 0662
Fax: 0131
Email: clairejackson@doctors.org.uk
Abstract
We describe a case of a torted caecal appendix epiploica causing acute abdominal pain. This entity has not been described in children. This case also illustrates the use of laparoscopy in the diagnosis and management of acute abdominal pain in childhood.
Key words: Appendix epiploicae, childhood, abdominal pain, laparoscopy
Case report
A previously fit and well 12 year old boy presented with a 12 hour history of constant right sided abdominal pain, associated with nausea but no vomiting. The pain had worsened over time and was exacerbated with movement. During this period he had passed three loose stools without blood or mucous. On examination he was apyrexial and haemodynamically stable. Examination of the abdomen revealed localised right iliac fossa tenderness but no peritonism. Urinalysis was negative. He was actively observed over a 24 hour period, during which he remained apyrexial but his tenderness increased. A diagnostic laparoscopy was performed. A 10 mm camera was inserted via an umbilical port introduced by an open technique. The findings were of a normal appendix and a ‘bean shaped’ necrotic lesion arising from the antimesenteric border of the caecum (see figure 1). This was excised using an additional two 5mm ports. The appendix was left in situ. Post operatively the patient made a rapid recovery, being discharged 36 hours later, pain free. Histology of the resected specimen was consistent with a torted appendix epiploica, showing fatty tissue with haemorrhagic stroma and a small amount of fibrovascular tissue at one edge (see figure 2).
Discussion:
Acute abdominal pain is a common presenting feature in our department. Clinical signs may indicate the need for surgery, either at presentation or after a period of active observation. However, in the majority of cases, children’s symptoms improve without surgical intervention. This case was unusual, as the child had localised abdominal signs without significant systemic upset. Laparoscopy was chosen as the investigation of choice, allowing visualisation of the whole abdomen, and definitive treatment.
A number of case reports exist in the literature of infarction of an appendix epiploica in adulthood1 although not in childhood. The clinical picture generally mimics that of acute appendicitis, with localised abdominal pain and tenderness. Ultrasonography may show secondary changes with omental thickening; CT scanning may reveal a fatty lesion1 but its routine use and associated radiation dose cannot be recommended. Untreated, a torted appendix epiploicae may lead to peritonitis or intestinal obstruction2 and pericolic abscess formation has also been described3.
The diagnosis of a torted appendix epiploica should be recalled in the differential for acute abdominal pain in all ages and can be a cause of abdominal pain following previous appendicectomy1. It can closely mimic acute appendicitis and could be missed at open appendicectomy through a limited incision. The decision to operate on a child with acute abdominal pain still relies primarily on symptoms and clinical signs but this case illustrates the benefit of laparoscopy in the management of acute abdominal pain in childhood where the diagnosis remains in doubt.
References
- Unal E, Yankol Y, Sanal T et al. Laparoscopic resection of a torsioned appendix epiploica in a previously appendectomized patient. Surg Laparosc Endosc Percutan Tech 2005; 15:371-373
- Shamblin JR, Payne CL, Soileau MK. Infarction of an epiploic appendix. South Med J 1986; 79:374-375
- Romaniuk CS, Simpkins KC. Case report: pericolic abscess secondary to torsion of an appendix epiploica. Clin Radiol 1993; 47:216-217