Pitfalls of Diagnosing Left Lower Quadrant Pain Causes: Making the Uncommon Common Again

Abstract

Patient: Male, 27Final Diagnosis: AppendicitisSymptoms: Abdominal discomfortMedication: —Clinical Procedure: —Specialty: SurgeryObjective:Rare diseaseBackground:Left-sided acute appendicitis, although well described in the literature, is still an easily missed diagnosis. Midgut malrotation and situs inversus are 2 known leading conditions that contribute to misdiagnosis of appendicitis.Case Report:Here is the case of a 27-year-old male without any previous medical history, who presented with left lower quadrant tenderness and was misdiagnosed with gastroenteritis as an outpatient and sent home; the patient presented the next day to the emergency department where he was found to have acute appendicitis with situs inversus. He underwent laparoscopic appendectomy where a phlegmon was identified. Pathology came back as peri-appendiceal mucocele with no signs of malignancy.Conclusions:This case report aimed to revisit the idea of left-sided acute appendicitis and discuss the management of a perforated appendiceal mucocele contained by a phlegmon.

Left-sided acute appendicitis in a patient with situs viscerum inversus totalis: A case report

“…AA is still one of the most common surgical emergencies with low morbidity and mortality if surgical treatment is not delayed. Mortality increases if surgical treatment is delayed [19] , often caused by misdiagnosis of AA. The mortality rate of AA is reported to be less than 1%, but it can be increased up to 5% in delayed diagnosed AA [4] .…”

Acute appendicitis in a patient with situs viscerum inversus totalis: Role of laparoscopic approach. A case report and brief literature review

“…Non-specific abdominal pain (NSAP) must also be considered in differential diagnosis [ 23 , 24 ]. Left-sided acute appendicitis occurs mainly in association with two uncommon clinical pictures: midgut malrotation and situs viscerum inversus totalis [ 25 ]. These two conditions complicate diagnosis and management of acute abdominal pain [ 16 ].…”

“…The incidence of this condition is around 0,03–0,5% [ 17 ] and can manifest itself in the first month of life (usually with bowel dysfunction and bilious vomiting), but in most of the cases it is a silent anomaly [ 16 ]. Situs viscerum inversus totalis (SVIT) instead is a rare autosomal recessive congenital pathology due to a defect localized on the long arm of chromosome 14 [ 18 ], in which there is a reverse anatomy and visceral organs are disposed in a mirror image [ 19 , 25 ]. The incidence of this condition is approximately of 1 per 10.000 [ 26 ] and most of patients with SVIT is asymptomatic and have a normal life expectancy.…”

“…We evaluated only publications in English language and we excluded articles that did not consider surgical treatment but only radiological diagnosis or anesthesiologic management. Only 4 patients were treated with laparoscopic approach [ 20 , [37] , [38] , [39] ] and one patients with single-incision technique [ 40 ]. In these cases the authors described the advantages of laparoscopy in differential diagnosis and surgical treatment, but with several difficulty related to different operating field with “mirror image” and reverse laparoscopic view that can be represent a technical challenge also for experienced surgeon.…”

A Case Report on Left-sided Appendicitis with Intestinal Malrotation

“…Differentials of left lower quadrant pain include colitis, diverticulitis, inflammatory bowel disease, intestinal obstruction (including volvulus) or perforation, nephrolithiasis, pyelonephritis, testicular torsion, epididymitis, atypical right-sided appendicitis, left-sided appendicitis, and left-sided primary epiploic appendagitis [7,8].…”