The British Journal of Radiology, 74 (2001), 1062–1064
Case report
Strangulated small bowel obstruction related to chronic
torsion of an epiploic appendix: CT findings
A OSADCHY, MD, M SHAPIRO-FEINBERG, MD and R ZISSIN, MD
Department of Diagnostic Imaging, Meir Hospital, Sapir Medical Center, Kfar-Saba, affiliated to the Sackler
School of Medicine, Tel Aviv University, Tel Aviv, Israel
Abstract. The role of CT in the evaluation of patients with small bowel obstruction, with
emphasis on the findings of strangulating obstruction, has been extensively described in the
literature. We report a rare case of small bowel volvulus related to a heterogeneous abdominal
mass detected on CT. On microscopic examination the mass proved to be a chronically torted
epiploic appendix.
CT now plays an important role in the
evaluation and management of patients with
small bowel obstruction (SBO), establishing the
correct diagnosis, defining a possible aetiology
and eliciting signs of strangulation requiring
surgical intervention [1–4]. A high diagnostic
accuracy of abdominal CT in differentiating
simple and strangulated SBO has been recently
reported [2–4], leading to increasing use of this
modality in the appropriate clinical setting. We
have encountered a case of SBO as the result of
volvulus of a bowel segment around a mass
proved to be a torted epiploic appendix (EA).
Torsion of an EA is an infrequent condition with
confusing clinical symptoms and its diagnosis can
easily be overlooked [5–7].
Case report
An 86-year-old man was admitted with a 1-day
history of gradually worsening vomiting and
epigastric pain. A nasogastric tube was inserted
and 3 L of coffee ground fluid were drained. His
medical history included diabetes mellitus and no
previous abdominal operations. Physical exami-
nation showed diffuse abdominal tenderness with
decreased peristalsis. Laboratory tests were un-
remarkable. Plain abdominal radiographs showed
dilatation of small bowel loops with air–fluid
levels, compatible with SBO. Abdominal CT
following both oral and iv contrast medium
was then performed. Dilated, thick-walled small
bowel loops with a radial distribution converging
Received 16 February 2001 and in revised form 10 May
2001, accepted 15 May 2001.
Address correspondence to Dr A Osadchy, Department
of Diagnostic Imaging, Sapir Medical Center, Kfar
Saba, 44281, Israel.
1062
E 2001 The British Institute of Radiology
towards a 565 cm2 mass consisting of soft tissue,
fat and peripheral calcified foci in the right lower
quadrant were seen on CT. Mesenteric vascular
engorgement, mesenteric haziness and fluid, and a
small amount of peritoneal fluid were also demon-
strated (Figures 1a–c). These findings were inter-
preted as strangulated SBO related to an
indeterminate mass. At surgery, bloody peritoneal
fluid and a closed loop of strangulated and
ischaemic terminal ileum were found. An adherent
band coursing from the mesenteric border of the
affected small bowel to an egg-sized tumour acted
as an axis for the small bowel volvulus. This band
was released and the gangrenous bowel loop and
tumour were then resected. Histology of the
surgical specimen showed ischaemic bowel and a
calcified infarcted EA. The post-operative course
was uneventful.
Discussion
The EAs have no known function. They are
more common on the transverse and pelvic colon,
being rarely found on the vermiform appendix
and on the small bowel. EAs vary considerably in
size, shape and contour in various parts of the
colon, with an average length of 3 cm, the longest
being in the sigmoid colon. Their blood supply
is derived from the superior and inferior mesen-
teric arteries, with venous drainage into the
corresponding veins and occasionally the renal
veins [6].
The most common complications of EA are
inflammation and torsion, either acute or chronic.
With torsion, the EA twists on its long axis,
leading to venous obstruction and oedema, with
further vascular impairment causing infarction
and gangrene. Acute torsion usually presents with
localized symptoms and signs of peritonitis in the
The British Journal of Radiology, November 2001
Case report: Small bowel volvulus caused by torted epiploic appendix
(a)
(c)
lower quadrants of the abdomen, including
guarding and rebound tenderness [5, 7]. Chronic
torsion usually goes unrecognized clinically and
produces saponification, with calcification of the
fatty organ leading to the formation of a mass [6].
When the mass is large enough it can be palpated
or may be detected on CT as a heterogeneous
mass, as was the case in our patient. Infrequently,
the long-standing infarction may cause amputa-
tion of the EA, which may then appear as a loose
calcified peritoneal body [8]. As evidenced by the
paucity of reported cases, torsion of an EA is a
rare condition with a confusing clinical presenta-
tion. The diagnosis may therefore be delayed or
missed [5–7]. Our case is very unusual, not only
for the rarity of this entity but also for the
resulting SBO, which has not been reported
previously in relation to EA torsion. A case
with similar CT findings of small bowel volvulus,
but connected to a calcified mesenteric lymph
node, has recently been reported [9].
As CT is often performed for various acute and
chronic abdominal conditions, the radiologist
should be aware of the possibility of this rare
entity of chronic torsion and necrosis of the EA,
which may be first recognized on CT as a
heterogeneous mass containing fat and calcium.
The British Journal of Radiology, November 2001
(b)
Figure 1. (a) Contrast enhanced CT at mid abdomen
level shows distended small bowel loops, contrast-
filled loops without mural thickening, and fluid-filled,
thick-walled loops, with engorged mesenteric vessels
(black arrowheads) indicating volvulus. Note the
collapsed small bowel loops in the right abdomen,
distal to the strangulating obstruction (white arrow).
(b) At the pelvis, dilated, thick-walled small bowel
loops with a radial distribution converge towards a
mass in the right lower quadrant (arrow). Note the
mesenteric haziness. (c) Image 1.5 cm caudal to (b)
shows the complexity of the mass (white arrow),
consisting of soft tissue, fat (black arrowhead) and
peripheral calcified flecks.
Acknowledgment
We gratefully acknowledge Prof. M Hertz for her
assistance in the preparation of this manuscript.
References
1. Tourel PG, Fabre JM, Pradel JA, Seneterre EJ,
Megibow AJ, Bruel JM. Value of CT in the diagnosis
and management of patients with suspected acute
small bowel obstruction. AJR 1995;165:1187–92.
2. Makita O, Ikushima I, Matsumoto N, Arikawa K,
Yamashita Y, Takahashi M. CT differentiation
between necrotic and nonnecrotic small bowel in
closed loop and strangulating obstruction. Abdom
Imaging 1999;24:120–4.
3. Ha HK, Kim JS, Lee MS, et al. Differentiation of
simple and strangulated small bowel obstruction:
usefulness of known CT criteria. Radiology
1997;204:507–12.
4. Balthazar EJ, Liebeskind ME, Macari M. Intestinal
ischemia in patients in whom small bowel obstruc-
tion is suspected: evaluation of accuracy, limitations
and clinical implications of CT in diagnosis.
Radiology 1997;205:519–22.
5. Shamblin JR, Payne CL, Soileau MK. Infarction of
an epiploic appendix. South Med J 1986;79:374–5.
6. Chatziioannov AN, Asimacopoulos PJ, Malone RS,
Pneumaticos SG, Safi HJ. Torsion, necrosis, and
inflammation of an epiploic appendix of the large
bowel: a diagnostic and therapeutic dilemma. South
Med J 1995;88:662–3.
1063
 A Osadchy, M Shapiro-Feinberg and R Zissin

7. Mazza D, Fabiani P, Casaccia M, Baldini E, 9. Qayyum A, Cowling MG, Adam EJ. Small bowel
Gugenheim J, Mouiel J. A rare laparoscopic diagnosis volvulus related to a calcified mesenteric lymph node.
in acute abdominal pain: torsion of epiploic appendix. Clin Radiol 2000;55:483–5.
Surg Laparosc Endosc 1997;7:456–8.
8. Borg SA, Whitehouse GH, Griffiths GJ. A mobile
calcified amputated appendix epiploicae. AJR 1976;
127:349–50.

1064 The British Journal of Radiology, November 2001