65 - Preissitzung
16. Mai 2019, 13:45 - 15:15, Sopra 3, 4. OG
Atypical left-sided appendicitis in two patients with midgut malrotation
S. Vanoli1, L. Salomon2, M. K. Peter1, A. Miftaroski2, M. Kauper1, B. Egger2, Presenter: L. Salomon2 (1Tafers, 2Fribourg)
Appendicitis is a very common surgical disease with various clinical manifestations. In some rare cases, patients may present a genetic midgut malrotation where the small bowel occupies the right peritoneal cavity and the colon is completely displaced to the left side. (incidence: 0.2-1% of 500 live births)1 With this condition, diagnosis of acute appendicitis can be challenging due to the unusual localization of symptoms. We present two cases of atypical appendicitis with left upper quadrant pain.
A 17 and 65-year-old patient were admitted to our hospital with sudden intense left upper quadrant pain. Physical examination showed a distended abdomen with peritoneal inflammatory signs at the left hypochondrium. Laboratory tests revealed leukocytosis and elevated CRP levels (12 mg/l and 16 mg/l in case 1 and 2, respectively). CT-scans were performed after non-conclusive ultrasounds and in both patients complete midgut malrotation with an appendix in the left upper quadrant and inflammatory signs compatible with appendicitis were detected.
Laparoscopic appendectomy has been performed in both patients. Intraoperative findings confirmed diagnosis of acute appendicitis in both with the caecum located in the left hemiabdomen next to the sigmoid. Also histopathological analysis confirmed in both patients an acute appendicitis and postoperative follow-up was uneventful in both with normalization of pain and inflammatory signs. Both patients were discharged home in good general condition at postoperative day 2 and 3, respectively and both follow up’s at 6 weeks with laboratory and clinical controls showed complete relief.
Midgut malrotation is a rare genetic malformation which may affect the clinical presentation of common surgical diseases, as appendicitis. Therefore, appendicitis should always be considered in the differential diagnosis of any abdominal pain. Some authors propose the Ladd procedure to correct the malrotation during the same operation (appendectomy) but the evidence is scarce with a lack of consensus and clear guidelines concerningly. 1 Skandalakis JE, Gray SW, Ricketts R, et al. The small intestines. Embryology for surgeons. 2nd ed. Baltimore: Williams and Wilkins; 1994. p. 84-241