Torsion of the Epiploic Appendage

21-year-old woman presented with a 5-day history of left-sided abdominal pain. She was treated with oral antibiotics for a presumed diagnosis of colitis but continued to have pain. Abdominal CT showed asymmetric bowel wall thickening in the descending colon associated with pericolonic inflammation. Adjacent to the bowel wall thickening was an ovoid mass slightly higher in attenuation than the peritoneal fat, surrounded by a rim of high attenuation (Fig. 1A). The patient’s symptoms did not improve with medical therapy. Diagnostic laparoscopy revealed an inflammatory mass adherent to the bowel wall of the descending colon. The mass was excised. Final pathologic diagnosis was necrotic appendix epiploica with surrounding hemorrhage (Fig. 1B). Epiploic appendixes are small (0.5‐5.0 cm long) pouches of peritoneum filled with fat and small vessels that protrude from the serosal surface of the colon. They occur in the rectosigmoid junction (57%), ileocecal region (26%), ascending colon (9%), transverse colon (6%), and descending colon (2%) [1]. Occasionally they are found on the appendix or small bowel. Possible complications associated with epiploic appendages include inflammation or torsion (73%), intrahernial content (18%), obstruction (8%), intraperitoneal loose bodies, and low colonic intussusception [1]. Epiploic appendagitis, denoting inflammation of an epiploic appendix from any cause, may be primary or secondary. Primary epiploic appendagitis is caused by torsion or spontaneous venous thrombosis of the involved epiploic appendage. Secondary epiploic appendagitis is associated with inflammation of adjacent organs, such as diverticulitis, appendicitis, or cholecystitis. Primary epiploic appendagitis occurs in the second to fifth decades of life without sexual predominance. Patients may present with localized abdominal pain of variable intensity and duration, rebound tenderness, an abdominal mass, mild fever, and mild leukocytosis. The nonspecific symptoms may mimic appendicitis, diverticulitis, omental infarction, pelvic inflammatory disease, or a ruptured ovarian cyst. Until the advent of sonography and CT, primary epiploic appendagitis was rarely diagnosed correctly before surgery. On sonography, primary epiploic appendagitis appears as a solid, hyperechoic, noncompressible ovoid mass surrounded by a subtle hypoechoic line [2]. Mass effect on the adjacent bowel wall and anterior parietal peritoneum is seen in 71% and 93% of cases,