Signs in Imaging

Radiology

Adriaan C. van Breda Vriesman, MD

The Hyperattenuating Ring Sign1

APPEARANCE

The hyperattenuating ring sign is a finding seen on computed

tomographic (CT) scans of the abdomen. It consists of a thin
round or oval ring of soft-tissue attenuation surrounding an
area of fat attenuation adjacent to the colon (Fig 1).

EXPLANATION

A hyperattenuating ring is a characteristic finding of primary

epiploic appendagitis (1,2). The ring represents thickening of
the visceral peritoneum surrounding an inflamed epiploic ap-
pendix (3). At histologic examination, the visceral peritoneal
lining of the diseased epiploic appendix is covered with a
fibrinoleukocytic exudate (1).

DISCUSSION

Epiploic appendices are small lobulated masses of pericolonic

fat protruding from the serosal surface of the colon. Normally
they can be seen on CT scans only when outlined by peritoneal
cavity fluid (Fig 2). An epiploic appendix may undergo infarc-
tion as a result of either torsion along its pedicle with compro-
mise of the blood supply or spontaneous venous thrombosis,
followed by secondary inflammatory changes (1). The condi-
tion has been termed primary epiploic appendagitis to avoid
confusion with appendicitis and to discriminate primary spon-
taneous inflammation from secondary epiploic appendagitis
caused by inflammation of adjacent organs.
The main symptom in patients with primary epiploic ap-
pendagitis is abrupt onset of focal abdominal pain in the
absence of other clinically important findings. The patient
usually does not appear very ill, and the white blood cell count
is either normal or moderately elevated (4). These findings are
Index terms:
Appendix epiploica
Colon, CT, 75.12112
Signs in Imaging
Published online before print
10.1148/radiol.2262011992
Radiology 2003; 226:556 –557
Figure 1. Hyperattenuating ring sign. Transverse CT scan of the
abdomen after intravenous administration of contrast material in a
42-year-old man with a clinical diagnosis of presumed appendicitis
depicts a pericolonic lesion with fat attenuation surrounded by a
hyperattenuating ring (arrowhead). The ring represents thickening of
the visceral peritoneal lining of an inflamed epiploic appendix.
nonspecific and do not allow clinical differentiation of epiploic
appendagitis from other common causes of acute abdominal
pain, leading to a clinical misdiagnosis in practically all cases (5).
Depending on the location, primary epiploic appendagitis may
simulate nearly any acute abdominal condition, but since the
infarction is frequently located in the lower quadrants, where the
sigmoid colon and cecum harbor the largest number of epiploic
appendices (6), the presumed clinical diagnosis is colonic diver-
ticulitis or appendicitis in most cases.
Primary epiploic appendagitis is a benign self-limiting dis-
ease, with spontaneous symptom resolution within 1 week in
most patients (1–3). Misdiagnosis, therefore, may lead to un-
warranted surgery or unnecessary medical treatment and hos-
pitalization. A correct imaging diagnosis of primary epiploic
appendagitis can prevent this overtreatment.

1
From the Department of Radiology, Westeinde Hospital, Lijnbaan
32, The Hague, the Netherlands. Received December 5, 2001; revi-
sion requested February 18, 2002; revision received March 13; ac- A trainee (resident or fellow) wishing to submit a manuscript
cepted April 2. Address correspondence to the author (e-mail: for Signs in Imaging should first write to the Editor for approval
adriaanbreda@hotmail.com). of the sign to be prepared, to avoid duplicate preparation of the
©
RSNA, 2003 same sign.

556
Radiology
Figure 2. Normal epiploic appendices. Non-
enhanced CT image in a patient with hepatic
cirrhosis shows several epiploic appendices (ar-
rowheads) outlined by ascites.
The imaging features of primary epiploic appendagitis have
been described as characteristic, allowing a definite diagnosis
(1–3,7). On CT scans, the finding of a 1– 4-cm-diameter perico-
lonic mass with fat attenuation, circumscribed by a 2–3-mm-
thick hyperattenuating ring, is diagnostic of primary epiploic
appendagitis. The hyperattenuating ring may be subtle, but its
presence has been mentioned in all cases of primary epiploic
appendagitis reported in the radiology literature. Occasionally,
the lesion may contain a central hyperattenuating area (Fig 3),
presumably caused by thrombosed vessels and hemorrhagic ne-
crosis (1). Additional CT findings include periappendageal fat
stranding and thickening of the parietal peritoneum. Local reac-
tive bowel wall thickening may be present, although it is typically
absent.
Ultrasonographic (US) findings in patients with primary epip-
loic appendagitis include a hyperechoic noncompressible ovoid
or round mass adherent to the colonic wall, frequently sur-
rounded by a hypoechoic border corresponding to the hyperat-
tenuating ring on CT scans. Although US has the advantage of
correlation of the location of the lesion and the location of
maximum tenderness as identified by the patient, CT should be
used to confirm the fatty nature of the mass before a definite
diagnosis of primary epiploic appendagitis is assigned (7).
The differential diagnosis of primary epiploic appendagitis,
based on imaging findings, is limited and includes secondary
epiploic appendagitis and omental infarction (1–3). Colonic di-
verticulitis is a common cause of secondary epiploic appendagi-
tis, and care should be taken to exclude findings suggesting the
diagnosis of it at US or CT (eg, presence of a diverticulum close to
the inflamed fat, inflammatory colonic wall thickening, abscess).
In difficult cases, color Doppler US might be useful in differenti-
ating inflammatory from ischemic lesions (8). Omental infarc-
tion may also simulate primary epiploic appendagitis, although
in omental infarction, the lesion is usually larger (average diam-
eter of 3.5–7.0 cm), cake shaped, and typically right sided (1,2). In
omental infarction, CT does not depict a hyperattenuating ring
surrounding the lesion, but in cases in which the presence of a
hyperattenuating ring is uncertain, discrimination of primary
epiploic appendagitis from omental infarction may be difficult.
Because omental infarction has a benign natural history similar
Volume 226 䡠 Number 2
Figure 3. Primary epiploic appendagitis in a
51-year-old woman with a clinical diagnosis of
presumed colonic diverticulitis. Nonenhanced
CT scan shows a pericolonic fatty lesion sur-
rounded by a hyperattenuating ring (arrow-
head), containing a central hyperattenuating
area (arrow) corresponding to thrombosis and
hemorrhagic changes. In the absence of diver-
ticula in the region of the inflammation, diver-
ticulitis can be ruled out. With conservative
treatment, symptoms resolved within 3 days.
to that of primary epiploic appendagitis, the distinction has no
practical implications (2).
Primary epiploic appendagitis may occur at any age, includ-
ing childhood, with a peak incidence in the 5th decade, with a
slight male preponderance (4). The onset of pain may follow
physical exertion, and obesity is a presumed predisposing fac-
tor (1,2). Though uncommon, the disorder is not as rare as
generally assumed. Primary epiploic appendagitis has been
reported in 2.3%–7.1% of patients clinically suspected of hav-
ing colonic diverticulitis and in 1.0% of patients suspected of
having appendicitis (3,7).
In summary, a hyperattenuating ring is a characteristic sign
of primary epiploic appendagitis. The finding enables the im-
aging diagnosis, thereby avoiding unnecessary treatment.
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