Torsion of Epiploic Appendix Following Chiropractic Movements: A Case Report

An epileptic appendix torsion is a rare event that can lead to acute abdominal pain and occurs at any age. Chiropractic is a type of complementary medicine that is performed explicitly by spinal manipulations. Specialists use spinal manipulation to treat many musculoskeletal disorders, usually mechanical back and neck pain, headaches, and spinal stiffness.


Background
The appendices epiploicae, or epiploic appendages, are small, mobile peritoneal sacs lled with fat that in each adult have about 50 to 100 appendages 2-5 cm long and 1-2 cm thick along the large intestine [1,2]. One or two terminal arteries supply these appendages, but only one vessel drains them, making them at risk for torsion and therefore susceptible to ischemic stroke, spontaneous venous thrombosis, Acute abdominal pain (AAP), and in ammatory reactions [3].
AAP, usually de ned as pain of nontraumatic origin with a maximum duration of ve days, is one of the most common complaints bringing people to the emergency department (ED), accounting for almost 10% of all ED referrals [4]. Despite its relatively wide variety of origin and frequency, AAP's cause may vary from lifethreatening illnesses requiring emergency surgery to mild self-limiting diseases that complicate the differential diagnosis [5,6].
One of the conditions leading to AAP is torsion of epiploic appendicitis, which is rare and may occur in young to middle-aged patients. The pain location can change based on the in amed appendix's position to mimic various diseases, such as acute appendicitis, acute cholecystitis, or acute diverticulum [7].
Chiropractic is a complementary and alternative medicine that works on the basis that the nervous system is the most important determinant of a person's health status. The speci c treatment of chiropractic is spinal manipulation [8]. Physiotherapists, chiropractors, and other physicians use spinal manipulation to treat plenty of musculoskeletal disorders, usually mechanical back and neck pain, headaches, and spinal stiffness [9]. This report documents the rst known colon epiploic appendix torsion case occurring after chiropractic manipulation to treat musculoskeletal disorders.

Case Presentation
A 49-year-old man presented to the emergency department of Ghaem Hospital due to diffuse abdominal pain with a predominance of the left lower quadrant. His pain started about three days ago and had progressed since then. During the clinical examination, the patient said that the pain was not localized and that the pain's intensity was constantly increasing throughout the abdomen. The patient gives a history of musculoskeletal pain from several years ago treated by chiropractic moves. The patient mentions that his pain started after the last chiropractic exercise. His body temperature was 38.7 °C, blood pressure was mmHg, heart rate was 87 beats/minute, and respiratory rate was 18 breaths/min.
During the clinical examination, the patient was conscious and pale. Examination of the head, neck, lungs, and heart was normal. On abdominal examination, the patient had no surgical scar, distension, and hernia. On touch, the abdomen was soft with generalized tenderness with a predominance of the left lower quadrant and a rebound tenderness with no guarding in this area region. The rectal examination was normal. The patient was admitted due to severe abdominal pain.
Chest and abdomen X-rays and laboratory tests were performed.
In the CBC tests, he had no leukocytosis, and his hemoglobin and platelet counts were normal. His creatinine was 1.4 mg/dl, urea was 42 mg/dl, blood sugar was 106 mg/dl, and amylase was 34 U/L; hematology-CBC, hormone, and ABG tests were normal.
No speci c ndings have been reported on the posterior-anterior chest and the abdomen supine X-ray scans ( Fig. 1.). No abnormal ndings were reported on ultrasound. Due to his diagnosis's uncertainty, abdominal and pelvic CT scans (Fig. 2.) were also performed with and without oral and injectable contrast. CT scan showed mesenteric fat stranding in the distal descending colon. Differential diagnoses of acute cholecystitis, mesenteric ischemia, and colon appendix epiploic torsion were presented, and according to the clinical examination and test results, we considered colon appendix epiploic torsion as the nal diagnosis.
According to the CT scan, appendicular torsion of the colon appendix was suggested. Due to this diagnosis and the lack of progression of symptoms within 24 hours after admission, the decision was made for non-surgical treatment, including gastrointestinal rest, antibiotics, analgesics, and uid therapy.
Within 48 hours, the patient's general condition improved. The patient continued treatment with the diet and was discharged from the hospital one day after starting the diet with complete abdominal symptoms recovery.
In the 7-months follow-up of the patient, no consequent complications were observed. All patient's information remained con dential, and consent was obtained from the patient to report this case.

Discussion And Conclusions
Epiploic appendicitis (EA) is an unusual condition of the acute abdomen and rst described by Lynn et al. in 1956 [10]. EA is more likely to be due to epiploic appendix torsion or spontaneous thrombosis of the central vein draining the epiploic appendix. This condition can eventually lead to vascular occlusion and focal in ammation. There are two types of this condition, primary and secondary, the rst of which is more common and can occur at any age, but it peaks in the fourth and fth decades of life and is more common in men. In the second type, in ammation of the epiploic appendages occurs, spreading to surrounding organs and leading to diverticulitis, appendicitis, cholecystitis, or pancreatitis [1,11]. Complications of EA include extensive bleeding, pericardial abscesses, intestinal obstruction, perforation of the colon, and even death [12]. Risk factors for EA include obesity, hernias, overexertion, or strenuous exercise [13]. EA has no speci c symptoms, but the patient may complain of severe abdominal pain. They generally have no fever, nausea, vomiting, and no lumps in the abdomen or vagina [2]. The best way to diagnose EA is to use a CT scan or laparoscopy [2,11]. Due to the diagnosis's uncertainty based on pathological ndings and ultrasound, the patient was prescribed a CT scan in which the mesenteric fat strand, as shown in the distal colon.
Many surgeons regularly use spinal manipulation to treat low back pain and other musculoskeletal pain [14].
With respect to its safety, it appears that chiropractic treatment involving spinal manipulation therapy (SMT), soft tissue therapy (STT), modalities, stretching, and mobilizations are safe to provide to individuals for treatment of GI disorders like duodenal ulcer, improve vision (for a short time), palliative treatment in patients with deep vein thrombosis, and supportive treatment for patients with cervical radiculopathy. Despite the positive effects of this treatment, its physiological basis has not yet been determined [15][16][17][18][19].
Despite the positive effects we have mentioned, the negative effects have also been reported. It has been stated that for conditions other than back pain, there is no favorable outcome for the use of spinal manipulation, mainly because of the possibility of major complications, such as a stroke. Other possible adverse effects include vertebral artery stenosis due to intimal rupture resulting from excessive arterial strain during rotational manipulation [14]. The patient was treated for these movements due to his muscle pain history and suffered from abdominal pain after the last treatment.
One of the treatments recently mentioned for musculoskeletal pain is the use of chiropractic exercises. We are trying to say that these cases and treatments are not completely safe and can cause irreversible complications and diseases by reporting this case that the patient had acute abdominal pain after the last session of chiropractic movement treatment. Slowly, Therefore, it is recommended to avoid using these methods, mostly in cases performed by inexperienced people.