Abstract Acute appendicitis is the most common cause of right iliac fossa pain. However, if the appendix is normal at surgery, the surgeon has to search for other causes of acute abdominal pain including rare etiologies. Awareness of all causes of acute right iliac fossa pain and a high index of suspicion is essential for diagnosis of rare causes like torsion of appendix epiploica In addition, in some patients, two pathologies causing acute pain may coexist. It is to the authors&apos; knowledge that the simultaneous occurrence of torsion of appendix epiploica and acute appendicitis in a patient has not been previously reported, and is therefore discussed in this report. From th

Akhil Bhat

Ganapathy Iyer

Gpn Verma

M C Sharma

Rebecca Mathew

Vuthaluru Seenu

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Oman Medical Journal 2010, Volume 25, Issue 1, January 2010
Torsion of Appendix Epiploica: A Rare Cause of Acute Right 
Iliac Fossa Pain
Ganapathy Iyer,1 Vuthaluru Seenu,1 Akhil Bhat,1 MC Sharma,2 Rebecca Mathew,2
GPN Verma2
Abstract
Acute appendicitis is the most common cause of right iliac fossa 
pain. However, if the appendix is normal at surgery, the surgeon 
has to search for other causes of acute abdominal pain including 
rare etiologies. Awareness of all causes of acute right iliac fossa 
pain and a high index of suspicion is essential for diagnosis 
of rare causes like torsion of appendix epiploica In addition, in 
some patients, two pathologies causing acute pain may coexist. It 
is to the authors’ knowledge that the simultaneous occurrence of 
torsion of appendix epiploica and acute appendicitis in a patient 
has not been previously reported, and is therefore discussed in this 
report.
From the 1Department of Surgery, Oman Medical College, Sultanate of Oman. 
2Department of Surgery & Pathology, Sohar Hospital, Sultanate of Oman.
Received: 14 Oct 2009
Accepted: 01 Dec 2009
Address correspondence and reprint request to: Dr. Vuthaluru Seenu, Department of 
Surgery, Oman Medical College, Sultanate of Oman.
Email: varnaseenu@hotmail.com
Introduction
Acute appendicitis is the most common cause of right iliac 
fossa pain. Other common causes of acute right iliac fossa pain 
include Meckel’s diverticulitis, pelvic inflammatory disease, 
twisted ovarian cysts, regional ileitis and ureteric calculous. Very 
rarely, it can also be caused by torsion of appendices epiploaecae.1-5 
The simultaneous occurrence of torsion of appendix epiploica and 
acute appendicitis in a patient, as far as the authors are aware has 
not been previously reported. Preoperative diagnosis of torsion 
of appendix epiploica is extremely difficult and needs a very high 
index of suspicion. This is a report of torsion of appendix epiploica 
detected at operation in a patient who was also subsequently 
diagnosed to have acute appendicitis at histopathology.
Case report
A 21- year- old Omani male presented to the Accident and 
Emergency Department of Sohar Hospital, with a history of right 
iliac fossa pain of one day duration associated with nausea with 
no other gastrointestinal or urinary tract symptoms. The pain 
was of sudden onset, and was also severe, gripping, continuous 
and localized. The patient was nauseated but had no history 
of vomiting. He had no other gastrointestinal or urinary tract 
symptoms. On examination, the patient was comfortable, well 
built and his general condition was fair. His vitals were normal 
(Pulse: 99 beats/min, BP: 141/87mmHg, Temp: 37 c and RR: 20/
min). Abdominal examination revealed tenderness in the right 
iliac fossa with rebound and guarding. The rest of the abdomen 
was soft with normal bowel sounds. Per rectal examination was 
normal. Examination of other systems was also normal. Laboratory 
investigations revealed normal haemoglobin and elevated 
leukocyte counts of 11.6 K/uL, polymorphonuclear leucocytosis 
were also observed. Ultrasonography of the abdomen showed no 
free fluid, and although the appendix was not visualised, the rest of 
abdominal organs were normal. 
A diagnosis of acute appendicitis was made and the patient was 
taken up for emergency appendicectomy under general anaesthesia 
after obtaining informed consent. On opening the abdomen, one 
appendix epiploica over the ascending colon, close to the caecum 
The appendix was retrocaecal in location, kinked by adhesions 
but not found to be inflamed on gross examination. The diseased 
appendix epiploica was excised. As the operation was being 
performed through a McBurney’s incision and the appendix was 
kinked by adhesions, an appendicectomy was also performed. 
Both specimens were sent for histopathologic examination.
Figure 1: Operative photograph showing twisted and infarcted 
appendix epiploica. Arrrow pointing to taenia coli.
Post operative recovery was uneventful and the patient was 
discharged after four days. Histopathologic examination of the 
appendix epiploica revealed infarction of adipose tissue, congested 
was found to be twisted, infarcted and gangrenous. (Fig. 1) 
Iyer G, et al. OMJ. 25 (2010); doi:10.5001/omj.2010.18
Oman Medical Journal 2010, Volume 25, Issue 1, January 2010
blood vessels, areas of fresh haemorrhage and infiltration by foamy 
Sections from the appendix showed edema of the muscle 
coat and acute and chronic inflammatory cells infiltrate in the 
sub mucosa and muscle coat, (Fig. 3). There was no fibrinous 
exudate on the surface.  A final diagnosis of acute appendicitis and 
infarction of the appendix epiploica was made.
Figure 2: Photograph showing fresh haemorrhage and 
inflammatory exudates in adipose tissue suggestive of infarction.
Figure 3: Photomicrograph showing acute and chronic 
inflammatory exudate  in muscle coat reaching upto the serosa 
suggestive of acute appendicitis
Discussion
Epiploic appendages are small out-pouches filled with fat and small 
vessels (1 or 2 arterioles and venules) that are aligned along the 
serosal surface of the colon from the cecum to the recto-sigmoid 
junction.2 The distribution of the epiploicae is moderate on the 
ascending and descending colons and the greatest number usually 
appear on the transverse colon and sigmoid flexure.1 Their length 
lying in two rows parallel to the external surface of the three 
longitudinal muscle bands of the large intestine known as taenia 
coli.1,3 The exact function of appendices epiploicae is unknown. It 
has been suggested that they may have bacteriostatic properties, 
may serve as a protective cushion for blood vessels or may have a 
role in the absorptive actions of the large bowel.4
An appendix epiploica can undergo torsion (the most common 
complication) resulting in thrombosis, infarction, gangrene and 
abscess. The exact cause of torsion is unknown. It may develop as 
a consequence of sudden rotation of the body, or it may be due to 
a long pedicle, or the vein may be longer and may be more likely 
to twist around its accompanying artery, or it may be caused by 
excess fat in the pedicles.4 It can also cause intestinal obstruction 
by forming a band on the abdominal wall or an adjacent loop of 
bowel and thus kink the bowel; or a loop of small bowel may be 
caught under the adherent band, another possibility is that it may 
initiate an intussusceptions.4
There is no classical clinical picture of torsion of an appendix 
epiploica. It can occur at any age and there is no sex predilection. 
Pain is the most common complaint and may be acute or 
intermittent/ prolonged where the torsion untwists spontaneously 
and recurs again. The pain occurs in either the lower quadrant of 
the abdomen, but more frequently in the right iliac fossa, although 
the most common site of the lesion itself is the sigmoid colon.4 
This could be explained by the fact that the sigmoid colon may 
be redundant and the top of the loop may be lying in the right 
iliac fossa. Clinical examination of the patient revealed localized 
tenderness with rebound and guarding. A palpable mass is rarely 
found. The white cell count is usually either normal or only mildly 
elevated.2. 
Ultrasound findings include hyperechoic non-compressible 
pericolonic mass, frequently surrounded by a hypoechoic border.6,7 
CT scan may show a hyper-attenuated ring with adjacent fat 
stranding or a lobulated fatty mass (due to two or more contiguous 
infarcted epiploic appendages lying in close proximity).7 However, 
preoperative diagnosis of torsion of appendix epiploica is extremely 
difficult and needs a very high index of suspicion.
The treatment of torsion of appendices epiploicae is surgical 
excision. This can be done laparoscopically,8-11 or through open 
approach.1-5 It may be prudent to perform appendicectomy, 
especially if a patient is operated through a McBurney or Lanz 
incision. Additionally, rarely can a patient have acute appendicitis 
in addition to torsion of appendix epiploica. Sometimes it may not 
be possible to diagnose acute appendicitis on gross examination 
in situ as in the studied case. In the patient under discussion, the 
Torsion of Appendix Epiploica... Iyer et al.
macrophages, (Fig. 2). varies from 0.5 to 5 cm. There are between 50-100 appendages 
Oman Medical Journal 2010, Volume 25, Issue 1, January 2010
occurrence of two pathologies can be attributed to the presence of 
adhesions around both structures. The outcome following excision 
of the appendix epiploicae was excellent and recurrence of the 
torsion in other appendices epiploicae has not been reported. 
Conclusion
In conclusion, torsion of appendix epiploica is very rare and a 
preoperative diagnosis of torsion of appendix epiploica cannot 
be made with certainty. One must be aware of the entity so that 
it will not be missed at a laparotomy. A patient with torsion of 
the appendix epiploica can also have acute appendicitis. Hence, 
the appendix should always be examined at surgery. If a patient is 
operated through a right iliac fossa incision, it may be prudent to 
perform an appendicectomy, so as to avoid the confusion in future 
when the same patient presents with right iliac fossa pain at a later 
date.
Acknowledgements
The authors reported no conflict of interest and no funding was 
received on this work.
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Torsion of Appendix Epiploica: A Rare Cause of Acute Right Iliac Fossa Pain

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Torsion of Appendix Epiploica: A Rare Cause of Acute Right Iliac Fossa Pain

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