Title : A Case Report on Left-sided Appendicitis

First author

Himal Kharel, Tribhuvan University Teaching Hospital, Maharajgunj, POB #1524, Kathmandu,

Nepal

Email: pigzeni@gmail.com

Second author

Druva Shah, Tribhuvan University Teaching Hospital, Maharajgunj, POB #1524, Kathmandu,

Nepal

Email : drshah_dn@live.com

Third author

Namrata Khadka, Tribhuvan University Teaching Hospital, Maharajgunj, POB #1524,

Kathmandu, Nepal

Email : dr.namratakhadka@gmail.com

Fourth author

Zeni Kharel, Medical College, Kolkata 700073, India

Email: zenikharel11@gmail.com

Correspondence

Himal Kharel

Tribhuvan University Teaching Hospital, Maharajgunj, POB #1524, Kathmandu, Nepal

Phone No : +977-9863396053, +977-1-4486607

Email : pigzeni@gmail.com

Keywords : appendectomy; intestinal malrotation; left-sided appendicitis.

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Abstract

Background: Acute appendicitis is a mimicker of wide range of gastrointestinal and

genitourinary pathologies. The diagnosis becomes more challenging when it is associated with

intestinal malrotation. A rare case of acute appendicitis with intestinal malrotation is reported

below.

Case presentation : A 32 year old male presented with left-sided abdominal pain. CT and USG of

abdomen showed intestinal malrotation with acute appendicitis. Exploratory laparotomy and

appendectomy via midline incision was performed and the patient had no issues on follow-up.

Conclusion : Given the rarity of acute appendicitis associated with intestinal malrotation, the

guidelines regarding the management is lacking and needs further research.

Introduction

Intestinal malrotation refers to a wide variety of pathological conditions including non-rotation,

incomplete rotation, over rotation and malfixation. The incidence of intestinal malrotation is

around 1 in 6000 live births1. Its manifestation varies greatly in different subjects. Infants

usually present acutely with volvulus whereas adults experience chronic abdominal pain. A vast

majority of adult patients are asymptomatic, and malrotation is usually an incidental finding 2. In

contrast to intestinal malrotation, acute appendicitis is a relatively common disease with overall

lifetime risks for male and female being 8.6 and 6.7%, respectively 3. It is a mimicker of wide

range of gastrointestinal and genitourinary pathologies. The diagnosis becomes more

complicated when it manifests atypically as in intestinal malrotation. A case of intestinal

malrotation with acute appendicitis has been described.

Case presentation

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A 32-year old gentleman without known co-morbidities presented to emergency department of

Tribhuvan University Teaching Hospital, Maharajganj, with complaints of insidious,

progressive, constant pain in his left iliac fossa without radiation, nausea, vomiting and anorexia

for 2 days. There was no history of per rectal bleed, melena, fever or surgical intervention and

his bowel and bladder habits were normal. On examination, the patient was found to be

tachycardic. Abdominal examination revealed tenderness, rebound tenderness, guarding in left

iliac fossa with bowel sounds and normal digital rectal examination.

Routine investigations were normal except for leukocytosis (11,800 with 90% neutrophils).

USG showed non-compressible, blind ending, tubular structure with surrounding hyperechoic

mesentery with probe tenderness in left iliac fossa without any free fluid (Figure 1). The chest X-

ray showed no abnormalities. Contrast enhanced computerised tomography (CECT) of abdomen

showed large bowel predominantly on the left side and small bowel predominantly on the right

side. Superior mesenteric artery (SMA) and superior mesenteric vein (SMV) relation was

inverted with SMA on the right and SMV on the left side. Duodenum was absent in between the

SMA and aorta and was entirely on the right side (Figure 2). Appendix arising from cecum was

noted in the left iliac fossa (LIF) with thickened wall and periappendiceal fat stranding with two

appendiculoliths of 97 and 65 mm2 size (Figure 3 and 4).

Thus, the diagnosis of acute appendicitis with complete nonrotation of midgut was made.

Due to lack of surgeon's experience in performing laparoscopic surgery, relatively challenging

anatomy and anticipation of bands which may have been missed by imaging, laparoscopic

procedure was not used and surgery via midline incision was deemed appropriate. The intra

operative findings were inflamed appendix with appendiculolith with healthy base arising from

cecum which was fixed in left lower quadrant with minimal free fluid. Duodeno-jejunal flexure

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with whole small bowel was seen on right side and the large bowel was seen on left side (Figure

5). The postoperative period was uneventful and the diagnosis was correlated with

histopathological examination of appendix. Patient didn't have any issues during first follow up

visit. Patient was lost to further follow up which was later found out to be due to geographical

inaccessibility .The timeline is presented in Table 1.

Discussion

Embryological development of the gut is a complex process in which tubular structure undergoes

rotation and fixation. There is total of 270° counterclockwise rotation of midgut around the

superior mesenteric artery axis with 90° when the midgut herniates out and 180° when the

midgut reduces. If this process fails to occur normally, the result is midgut malrotation.

Malrotation includes under-rotation, over-rotation, reverse rotation and malfixation of intestine.

Malrotation is classified based on the timeframe in which it occurs.4

Acute appendicitis is a fairly common condition caused due to obstruction of lumen and

subsequent bacterial infection.3 It can co-exist with midgut malrotation which can sometimes

lead to a confusing clinical picture like in this case. A significant minority of left sided

appendicitis leads to presentation similar to that of right sided appendicitis with pain on right

iliac fossa.5

Midgut malrotation is associated with heterotaxy syndromes, other anomalies like annular

pancreas, jejunal stenosis, duodenal stenosis, Hirshprung's disease, congenital diaphragmatic

hernia, imperforate anus, Meckel's diverticulum, biliary atresia and omphalocele. It is especially

important to obtain Chest X-ray to rule out situs inversus totalis which may be confused with

intestinal malrotation. More than two-thirds of the left sided appendicitis are due to situs inversus

totalis rather than intestinal malrotation.5

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 The incidence of midgut volvulus in symptomatic malrotation was 42.1% in the neonatal

period, and 50% beyond the neonatal period.6 Midgut volvulus presents as abdominal pain and

bilious vomiting. But this is less common than more chronic presentations of abdominal pain,

failure to thrive and gastroesophageal reflux.7

There are different methods to diagnose midgut malrotation with appendicitis which includes

abdominal X-ray, Upper gastrointestinal (UGI) contrast studies, USG abdomen and CECT

abdomen. Abdominal X-ray shows paucity of small bowel air or may be completely normal. UGI

contrast studies shows abnormal position of duodenojejunal junction which is normally situated

to the left of the left sided pedicles of vertebral bodies. The sensitivity of the upper GI series for

the diagnosis of malrotation has been reported as 95%. 8 USG is considered to be the best initial

imaging modality especially for children. USG may show inversion of SMA and SMV

relationship with blind non-compressible aperistaltic tube on the left side. CECT abdomen may

also show inversion of SMA and SMV9 along with large bowel predominantly on left, small

bowel predominantly on right side and concomitant feature of acute appendicitis. Abnormalities

of the SMA and SMV relationship is not entirely diagnostic of intestinal malrotation.

When it presents as volvulus, Ladds procedure is generally performed with derotation of gut,

broadening of mesenteric base, division of Ladds bands, appendicectomy, fixing small bowel on

the right side and large bowel on the left side. It can be performed as open or laparoscopic

surgery.

If it is found incidentally either in asymptomatic patients or with other intraabdominal

pathology like acute appendicitis then Ladds procedure becomes optional. Laparoscopic

appendicectomy is considered to be gold standard of treatment of left sided appendicitis. But

unlike open procedures, laparoscopic procedures have a steep learning curve and are not well

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established in low resource settings like ours. Some recommend only correction of intestinal

pathology without Ladds procedure as the risk of complications following Ladds procedure

outweighs the risk of developing volvulus. While others recommend a more aggressive approach

to treat the asymptomatic malrotation as the consequences of volvulus are usually disastrous

including short gut syndrome and perforation peritonitis. But there is a lack of quality data to

guide the management of such patients.10

Conclusion

Left-sided appendicitis is a rare condition. It may present with features of diverticulitis. At

present, consensus among experts regarding the management of incidental malrotation is lacking.

List of abbreviations

CT = Computerised tomography

USG = Ultrasonography

CECT = Contrast Enhanced computerised tomography

SMA = Superior Mesenteric Artery

SMV = Superior Mesenteric Vein

LIF = Left illiac fossa

UGI = Upper Gastrointestinal

Declaration
 Ethics approval and consent to participate
Need for ethical approval waived. Consent from the patient deemed to be enough.
 Consent for publication
Written informed consent was obtained from the patient for publication of this case report and
any accompanying images. A copy of the written consent is available for review by the Editor-
in-Chief of this journal.
 Availability of data and material

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Data mentioned in the case report are available to the reviewers if required.
 Competing interests
The authors declare that they have no competing interests
 Funding
None
 Authors' contributions
HK gathered the data and wrote the parts of discussion section. DS and NK performed the
surgery and proof read the manuscript. ZK also wrote part of discussion.
 Acknowledgements
None

References

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