A diagnostic dilemma: Left-sided appendicitis in a 10 year old boy with previously undiagnosed intestinal malrotation. A case report

Abstract

HighlightsIntestinal malrotation is a congenital rotational anomaly that occurs as a result of an arrest of normal rotation of the embryonic gut, said to occur in 1 in 6000 live births. Once thought to be a disease of infancy, is now more prevalent in older ages.Cases of left sided appendicitis with previously undiagnosed intestinal malrotation therefore becomes more challenging to diagnose, and often time’s definitive surgical management is delayed. A varied list of differential diagnosis needs to be considered.This case presentation shows the difficulties encountered and the variation in presentation that lead us down a different path prior to attaining a formal diagnosis.CT abdomen was required to confirm the diagnosis, and in a paediatric age group, radiation exposure is always weighed upon risk-benefit ratio.Definitive management is surgical intervention.

Left sided acute appendicitis with intestinal malrotation in an adult, a diagnostic challenge

“…The incidence of acute appendicitis is 1.33 per 1000 in males and 0.99 per 1000 in females. 2 Shifting abdominal pain from epigastric region to the right lower abdomen with tenderness on compression are the classic clinical manifestations and usually associated with fever and vomiting. The appendix is normally less than 6 mm in diameter.…”

“…3 Left sided appendicitis is rare and the possibilities include an abnormally enlarged right sided appendix with the tip at the left or appendicitis associated with intestinal malrotation or situs inversus totalis. 2 Springer classified rotational abnormalities of the mid gut into three broad types as non-rotation, partial malrotation and reverse rotation.⁴ Nonrotation is the most common form of malrotation, where entire large bowel lies on the left hemi abdomen and duodenal junction lies to the right. The incidence of malrotation is 1 in 500 new born and 64-80 % of the neonates present within first month of life.…”

“…The incidence of malrotation is 1 in 500 new born and 64-80 % of the neonates present within first month of life. 2 Upper gastrointestinal series is the investigation of choice for diagnosis of malrotation in children and demonstrates failure of the duodenaljejunal junction to cross the midline and lies below duodenal bulb. 5,6 Intestinal malrotation in adult is uncommon and occasionally noted as incidental finding on adult population.…”

Left- sided Acute Appendicitis with Intestinal Malrotation in an Adult:a Diagnostic Challenge

“…The small bowel loops were located on the right side, whereas the large bowel loops were on the left (Fig.2). Likewise, the superior mesenteric artery was noted at the right of superior mesenteric vein, reversed relation (Fig.2), indicating Stringers Type I intestinal malrotation 1 . Normally the superior mesenteric vein lies right to the superior mesenteric artery 3 .…”

“…In addition malrotation presenting as acute left sided appendicitis is even rare with few individual case reports described in the literature. 1,2 The unusual clinical presentation of left lower abdominal pain without bowel and urinary symptoms should arise the possibility of this rare clinical entity. Contrast enhanced CT-scan of the abdomen and pelvis is the diagnostic method of choice which reveals the anatomic details of intestinal malrotation, findings of acute appendiceal inflammation and its possible complications.…”