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 Table of Contents  
CASE REPORT
Year : 2012  |  Volume : 4  |  Issue : 7  |  Page : 328-330

Type 3B malrotation presented with acute appendicitis as left renal colic


1 Department of Radiology, Kahramanmaras Sutcu Imam University, Kahramanmaras, Turkey
2 Department of Radiology, Elmadag State Hospital, Turkey
3 Department of Radiology, Hacettepe University, Ankara, Turkey

Date of Web Publication17-Jul-2012

Correspondence Address:
Fuat Ozkan
Department of Radiology, Kahramanmaras Sutcu Imam University, 46050 Yörükselim mah. Hastane cad. No:32, Kahramanmaras
Turkey
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/1947-2714.98597

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  Abstract 

Midgut malrotation is a rare anatomic anomaly that complicates the diagnosis and managemant of acute abdominal pain. It is a congenital anomaly that arises from incomplete rotation or abnormal position of the midgut during embryonic development. We report a case of a patient who have very rare form (Nonrotation of the proximal loop associated with partial rotation of the distal loop) of malrotation with ruptured appendicitis. Left-sided acute appendicitis should be considered in the differential diagnosis of patients with pain with localized in the left lower quadrant.

Keywords: Computed tomography, Left lower quadrant pain, Left-sided appendicitis, Midgut malrotation


How to cite this article:
Ozkan F, Yurttutan N, Inci MF, Akpinar E. Type 3B malrotation presented with acute appendicitis as left renal colic. North Am J Med Sci 2012;4:328-30

How to cite this URL:
Ozkan F, Yurttutan N, Inci MF, Akpinar E. Type 3B malrotation presented with acute appendicitis as left renal colic. North Am J Med Sci [serial online] 2012 [cited 2019 Dec 9];4:328-30. Available from: http://www.najms.org/text.asp?2012/4/7/328/98597


  Introduction Top


Acute appendicitis is the most common cause of emergency operations in gastrointestinal surgery. Approximately one-third of patients have pain localization except that the right lower quadrant because of the various positions of the appendix. Left quadrant pain because of appendicitis is a very rare condition and can occur with congenital abnormalities that include true left-sided appendix or as an atypical presentation of right-sided, but long appendix, which projects into the left quadrant. [1] Left-sided acute appendicitis develops in association with situs inversus totalis (SIT) or midgut malrotation (MM). Intestinal malrotation is a congenital anomaly that arises from incomplete rotation or abnormal position of the midgut during embryonic development.

Herein we report a case of a patient who have very rare form (nonrotation of the proximal loop associated with partial rotation of the distal loop) of malrotation with ruptured appendicitis.


  Case Report Top


A 52-year-old male with a 2-day history of left lower abdominal pain was admitted to a local hospital. He had been treated as left renal colic and given analgesic. Because of no recovery, he was transferred to our hospital. Physical examination revealed left lower quadrant tenderness and rebound tenderness without guarding. Laboratory test showed an elevated WBC count (20.1 × 10 9 /l) with neutrophils of 85%. Computed tomography (CT) showed incomplete intestinal malrotation findings, including a right-sided duodenojejunal junction, left-sided hepatic flexure, SMV inversion sign (is the name given to an SMV vertically above or left lateral to the superior mesenteric artery), situation of transverse colon on the left side of the spine, a midline-positioned dilated appendix with wall enhancement and small abscess formation [Figure 1]. These findings were diagnostic of nonrotation of the proximal loop associated with partial rotation of the distal loop form of malrotation with ruptured appendicitis. At laparotomy, the cecum was found in the midline small bowel was located in the right abdomen [Figure 2]. Appendectomy was performed. Pathology revealed ruptured appendicitis. He had an uneventful recovery.
Figure 1: CT scans show a right-sided duodenojejunal junction (arrow), left-sided hepatic flexure (thick arrow) (a), SMV inversion sign (arrowhead) with rightward direction of the first jejunal vessels (open arrow) (b), and midline-positioned swelling appendix with wall enhancement (long arrow) (c)

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Figure 2: Intraoperative photograph demonstrates intestinal malrotation. The small bowel is located in the right abdomen (open arrow) with the colon to the left (thick arrow) (a). Arrow shows inflamed appendix (arrow) (b)

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  Discussion Top


Left lower quadrant pain as manifestation of appendicitis is a very rare and misleading condition. Left-sided appendicitis occurs in association with two types of congenital anomalies: SIT and MM. Akbulut et al. reported a brief article which is the review of 95 published left-sided appendicitis. At that study congenital anomalies accompanying to the left-sided appendicitis were 69.4% SIT, 24.2% MM, 3% cecal malrotation, and 3% others. [2] Malrotation is defined as an anomaly of rotation and fixation of the midgut. Normally, the straight short primitive gut begins its rotation at the 4 th week of gestation, and the process is terminated by the 12 th week following a 270° counterclockwise rotation. [3] According to the stage of normal rotation at which arrest or error occurred, different types were identified. [3],[4] Balthazar divided these into complete or partial failures of rotation and into abnormalities affecting the duodenojejunal loop, the cecocolic loop, or both. [5] These abnormalities can be classified according to complete or partial failures of rotation and abnormalities affecting the duodenojejunal loop, the cecocolic loop, or both resulting in seven different types and degrees of malrotation. [3] In the most common type of malrotation (type Ia), the duodenum and large bowel stop rotation after 90°, so that the proximal small bowel, including the duodenojejunal junction, lies on the right and cecum lies on the left. Israelit et al. reported a case representing left-sided perforated acute appendicitis associated with type Ia MM. [6]

Our patient had type 3b malrotation according to Stringer classification which was the nonrotation of the proximal loop and partial rotation of the distal loop form of malrotation. In this form, colon is incompletely rotated and due to incomplete attaching of hepatic flexure, transverse colon is situated on the left side of the spine. The patient was asymptomatic during his life and was not diagnosed until the onset of acute pain. The location of his pain prevented correct clinical diagnosis, resulting in rupture and advanced disease.

Atypical presentations of acute appendicitis coincident with incomplete malrotation may mislead and subsequent delay therapeutic management in these patients. CT not only clarifies this unusual location of appendicitis but also is useful in detecting associated rotational anomalies and related complications that may require separate surgical correction. Left-sided acute appendicitis should be considered in the differential diagnosis of patients with pain with localized in the left lower quadrant.

 
  References Top

1.Hou SK, Chern CH, How CK, Kao WF, Chen JD, Wang LM, et al. Diagnosis of appendicitis with left lower quadrant pain. J Chin Med Assoc 2005;68:599-603.  Back to cited text no. 1
[PUBMED]  [FULLTEXT]  
2.Akbulut S, Ulku A, Senol A, Tas M, Yagmur Y. Left-sided appendicitis: Review of 95 published cases and a case report. World J Gastroenterol 2010;28:5598-602.  Back to cited text no. 2
    
3.Stringer DA, Jamieson D. Small bowel. In: Stringer DA, Babyn PS, editor. Pediatric gastrointestinal imaging and Intervention. 2 nd ed. London: B.C. Decker Inc; 2000. p. 311-475.   Back to cited text no. 3
    
4. Pinto A, Raimondo DD, Tuttolomondo A, Fernandeza P, Caroniab A, Lagallab R, et al. An atypical clinical presentation of acute appendicitis in a young man with midgut malrotation. Radiography 2007;13:164-8.  Back to cited text no. 4
    
5.Balthazar EJ. Intestinal malrotation in adults. Roentgenographic assessment with emphasis on isolated complete and partial nonrotations. AJR Am J Roentgenol 1976;126:358-67.  Back to cited text no. 5
[PUBMED]  [FULLTEXT]  
6.Israelit S, Brook OR, Nira BR, Guralnik L, Hershko D. Left-sided perforated acute appendicitis in an adult with midgut malrotation: The role of computed tomography. Emerg Radiol 2009;16:217-8.  Back to cited text no. 6
[PUBMED]  [FULLTEXT]  


    Figures

  [Figure 1], [Figure 2]


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