Left-sided appendicitis in a patient with congenital gastrointestinal malrotation: a case report

Abstract

Background: While appendicitis is the most common abdominal disease requiring surgical intervention seen in the emergency room setting, intestinal malrotation is relatively uncommon. When patients with asymptomatic undiagnosed gastrointestinal malrotation clinically present with abdominal pain, accurate diagnosis and definitive therapy may be delayed, possibly increasing the risk of morbidity and mortality. We present a case where CT was crucial diagnostically and helpful for pre-surgical planning in a patient presenting with an acute abdomen superimposed on complete congenital gastrointestinal malrotation.

Case presentation: A 46-year-old previously healthy male with four days of primarily left-sided abdominal pain, low-grade fevers, nausea and anorexia presented to the Emergency Department. His medical history was significant for poorly controlled diabetes and dyslipidemia. His white blood count at that time was elevated. Initial abdominal plain films suggested small bowel obstruction. A CT scan of the abdomen and pelvis was performed with oral and IV contrast to exclude diverticulitis, revealing acute appendicitis superimposed on congenital intestinal malrotation. Following consultation with the surgical team for surgical planning, the patient went on to laparoscopic appendectomy and did well postoperatively.

Conclusion: Atypical presentations of acute abdominal conditions superimposed on asymptomatic gastrointestinal malrotation can result in delays in delivery of definitive therapy and potentially increase morbidity and mortality if not diagnosed in a timely manner. Appropriate imaging can be helpful in hastening diagnosis and guiding intervention.

Figure 1

Abdominal plain films. Supine (A) and upright (B) abdominal plain films demonstrate multiple loops of dilated small bowel (arrows in A) with air/fluid levels (arrows in B) in the right abdomen, suggestive of small bowel obstruction; this finding can also be seen as an unusual sign of acute appendicitis. Intestinal malrotation was not considered at this time.

Figure 2

Abdominal CT: Atypical acute appendicitis. Axial spiral CT with oral and IV contrast (A) and coronal multiplanar reconstruction (B) demonstrate dilated appendix in the left mid-abdomen (arrows) with adjacent fat stranding.