Abstract
Paediatric abdominal pain continues to pose a diagnostic challenge in the acute hospital care setting. We describe an eleven-year-old boy who presented to the emergency department with acute-onset, sharp abdominal pain localised to right lower quadrant. Abdominal imaging was diagnostic for epiploic appendagitis (EA), with pathognomonic ‘ring sign’ and ‘central dot’ visualised on the axial computed tomography images. He responded well to conservative treatment, including a short course of non-steroidal anti-inflammatory drugs. EA is a lesser-known paediatric entity mimicking surgical conditions. However, steady but sharp and non-migratory characteristic of the pain in either of the lower abdominal quadrants should raise suspicion for EA. Early accurate diagnosis can prevent unnecessary surgical exploration in these patients.
Keywords: Paediatric abdominal pain, Acute abdomen, Epiploic appendagitis, Children, Computed tomography
1. Images in paediatrics
Paediatric abdominal pain continues to pose a diagnostic challenge in the emergency department. We describe the case of an apparently healthy, non-obese, 11-year-old boy who presented with acute-onset, constant, sharp abdominal pain for 2 days. The pain was localised to right lower quadrant, associated with nausea and exacerbated by movements. There was localised deep tenderness on palpation. Inflammatory markers were normal. The radiologist encountered probe tenderness but found normal appendix on ultrasonography. An oval fat-attenuated lesion was visualised on the right anti-mesenteric border of the colon on computed tomography (CT), characteristic of epiploic appendagitis (Fig. 1A, Fig. 1BA and B). The patient was prescribed ibuprofen and anti-emetics, following which his symptoms completely abated and continued to remain asymptomatic at 2 weeks follow-up.
Fig. 1A.
Contrast-enhanced axial CT image showing well-defined oval lesion (arrows) in the peritoneal appendages measuring 2 cm in diameter and 4 cm in length, with attenuation similar to that of fat. Surrounding inflammatory changes are seen in the form of a thin enhancing rim (ring sign), located anterolateral to the right colon.
Fig. 1B.
Evidence of irregular central increased echogenicity (2 arrows) suggestive of pathognomonic “central dot” sign of epiploic appendagitis, indicative of thrombosed vessel or haemorrhagic necrosis within the fat-attenuated lesion [1,5].
Epiploic appendagitis (EA), a self-limited inflammation or ischaemia of the small appendages along the surface of colonic mesentery, is considered a rare cause of paediatric abdominal pain. Necrosis and/or inflammation of the epiploic appendages is seen secondary to torsion, stretching and, occasionally, venous thrombosis [1]. Male gender, middle age, obesity, strenuous exercise and presence of hernia are some of the known risk factors [1,2]. EA is a lesser-known paediatric entity mimicking surgical conditions such as diverticulitis, seen commonly on the left side (60–80%) [1,3,4]. However, right-sided EA is often misdiagnosed as acute appendicitis and cholecystitis [2,5]. Steady but sharp and non-migratory characteristic of the pain in either of the lower abdominal quadrants should raise suspicion of EA [3].
Ultrasonography is the first line in the diagnostic algorithm. However, it has a low sensitivity and is operator dependent [4]. The most widely used modality in the imaging of EA is abdominal CT. Although it is associated with ionising radiation risk, the pathognomonic findings as seen in our case (Fig. 1A, Fig. 1B) make CT the diagnostic choice [2,5]. Routine use of MRI is not very well studied for EA; moreover, it involves sedation and higher cost [4]. In the index case, parents, after discussion with the clinical and radiological team, opted for a quick contrast-enhanced CT to establish the diagnosis following suspicious ultrasound findings.
Management is symptomatic with non-steroidal anti-inflammatory drugs and no role for antibiotics [2]. The pain resolves in most cases within 72 h [2,4]. Inflammatory markers are normal or only mildly elevated because of the localised and benign nature of the underlying pathology [1,4]. Though EA is considered rare, it is increasingly being recognised as a cause of paediatric abdominal pain with widespread access to imaging [4,5]. Early accurate diagnosis may prevent unnecessary surgical exploration unless the symptoms are persistent, severe or recurrent.
Ethical statement
All authors have complied with relevant policies for graphical images. We declare that the images provided in the article are original images. No manipulation has been done which could be seen as scientifically unethical.
Conflict of interest
The authors declare no conflict of interest.
Source of funding
No sponsors were involved in any stage of this manuscript preparation and publication.
Footnotes
Peer review under responsibility of King Faisal Specialist Hospital & Research Centre (General Organization), Saudi Arabia.
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