La tunisie Medicale - 2009 ; Vol 87 ( n°012 ) : 873-874
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Article

A 56-year-old man with a past medical history of diabetes mellitus was admitted to department B of General Surgery complaining left-sided abdominal pain, pyrexia and vomiting which started three days before admission. His last bowel movement was two days prior to presentation. Neither melena nor history of similar pain, or urinary symptoms was mentioned. The abdominal examination revealed left upper quadrant tenderness with localised rebound. Temperature was 38.2°C. White blood cell count was 11,600/mm3 and C-reactive protein was 87.2 mg/dl. Urine analysis was normal, with no evidence of infection or haematuria. This presentation evoked left colonic diverticulitis. A spiral CT scan of the abdomen and pelvis with oral and IV contrast showed a mobile cecum adjacent to the descending colon. An enlarged appendix, with wall thickening, projected leftward from the cecum was visualized suggesting an acute left-sided appendicitis. The descending and sigmoid colon appeared normal (Fig 1).
Laparoscopy showed a gangrenous appendix located in the left upper quadrant (Fig 2). A laparoscopic appendectomy was performed. Pathology revealed suppurative appendicitis with peri appendicitis. Postoperative course was uneventful and the patient was discharged the third postoperative day.

DISCUSSION


The patient in this case report with an intestinal malrotation had been asymptomatic until the recent onset of the acute abdominal pain.
Aleft-sided appendix occurs with an estimed frequency of 0.2% in the adult population.1 There are two anatomic abnormalities that result in a left-sided appendix, the first being situs inversus, and the second, less common, is intestinal malrotation. Intestinal malrotation is a result of failure or incomplete rotation of the midgut between the 4th and 12th week of gestation.2
When we are unaware of situs inversus or intestinal malrotation, left-sided abdominal pain cannot be related to acute appendicitis. In this situation, the CT scan is a useful tool for diagnosis identifying the intestinal malrotation and signs of acute appendicitis.
The laparoscopic approach is very interesting to confirm the diagnosis of intestinal malrotation and to allow the appendectomy.

 

Figure 1. CT scan of the abdomen and pelvis. (A) Small bowel positioned in the right abdomen and cecum located in the left mid
abdomen. (B) An enlarged appendix, with wall thickening, projected leftward from the cecum (see the white arrow).



Figure 2:
Laparoscopic appendectomy. (A) Port placement for laparoscopic left-sided appendectomy. (B) Intraoperative photography
showing a gangrenous appendix placed on the grip (see the black arrow).

Reference
  1. Schwartz JH, Manco LG. Left-sided appendicitis. J Am Coll Surg 2008;206:590.
  2. Nicholas JM, Rozycki GS. Image of the month. Arch Surg 2001;136:705-6.
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