Midgut Malrotation with Left-Sided Appendicitis
The diagnosis of left-sided acute appendicitis (LSAA) with midgut malrotation is rare. It often presents a dilemma for healthcare professionals, but it should always be considered in a patient with left-sided abdominal pain.
Midgut malrotation (MM) is primarily identified in pediatric patients, but it can also be present in adulthood. It is a congenital abnormality that arises when the midgut fails to rotate properly around the superior mesenteric vessels and assumes an abnormal position during the early stages of embryonic development. Malrotation may manifest as acute, intermittent, or asymptomatic episodes. The various types of midgut Malrotation are present which include non-rotation, incomplete rotation, and reverse rotation. Midgut Malrotation is a relatively uncommon congenital anatomical anomaly that complicates the diagnosis and management of sudden abdominal pain.
Acute appendicitis is a common cause of emergency presentations that require immediate surgical consultation and treatment. Most surgeons are trained to diagnose and treat right-sided appendicitis. However, they face a diagnostic challenge when encountering the left side of acute appendicitis.
This case presentation is about a 23-year-old Ethiopian male patient. The patient came to the hospital with complaints of pain in the upper abdomen and left-sided region. The pain was associated with vomiting. Moreover, the patient had also been experiencing low-grade fever and watery diarrhoea six to eight times daily. All of these conditions persisted for one day. The patient had no personal history of diabetes, hypertension, asthma, or any other medical conditions. Also, he denied any prior abdominal surgeries or history of abdominal trauma. He consumed alcohol occasionally but he was not a heavy drinker and had never faced similar illnesses in the past.
Examination and Investigations
The patient’s vital signs were within the normal range during the examination. This included a blood pressure of 110/75 mmHg, temperature of 36.9 °C, pulse rate of 84 beats per minute, and a respiratory rate of 14 breaths per minute. Additionally, the patient exhibited rebound tenderness in the left lower quadrant area of the abdomen.
The doctor conducted various laboratory tests. This includes a complete blood count, which revealed a Hct of 39.4, a white blood cell count of 4700 with 73% neutrophilia, and a platelet count of 230,000/mcl of blood. Additionally, the patient had a random blood sugar of 79 g/dL, serum electrolytes of Na-138 meq/L and K-3.7 meq/L), liver function tests of SGOT=24 U/L, SGPT=19 U/L, Albumin of 4.3 g/dL, and renal function tests of creatinine = 0.6 mg/dL and BUN=23. All were within the normal range. However, the doctors conducted a stool examination, which revealed the presence of trophozoites of Entamoeba histolytica leading to a diagnosis of amebic colitis. As a result, he was treated with intravenous metronidazole, which only worsened the patient’s abdominal pain.
For further investigations, the doctor conducted abdominal ultrasonography (USG), which showed normal findings except for the non-visualized appendix. In addition, the Contrast-Enhanced Computed Tomography (CT) of the abdomen revealed that the small bowel was positioned on the right half of the stomach. In contrast, the large bowel was located on the left half. Furthermore, fluid and free air were present within the peritoneal cavity. Also, the appendix was observed in the left lower quadrant, next to the junction of the left-sided ileocecal region.
The final diagnosis is left-side perforated appendicitis
All of the examinations and investigations confirmed that the patient had generalized peritonitis caused by a perforated appendix. As a result, an urgent laparotomy was performed. During the surgery, it was discovered that the entire colon was situated on the left side of the abdomen, while the whole small bowel was positioned on the right side. Also, the appendix was found on the left side with a perforation at the middle third of it. It was forming an adhesion with the greater omentum. In addition, 1 liter of thin pus was found in the peritoneal cavity.
As a result of these findings, the doctors drained the pus and immediately performed the appendectomy. Along with this, the peritoneum was rinsed with warm normal saline. Following the surgery, the patient was given ceftriaxone and metronidazole along with a painkiller called diclofenac. After the recovery, the patient was discharged home on the 6th postoperative day. He was followed up for 3 weeks with no complications.
The surgeons should be informed about this rare congenital anomaly and they should recognize its diverse presentation across different age groups to help in minimizing diagnostic delays and definitive management of the patient. Physicians, radiologists, and surgeons should possess knowledge about the embryology and anatomy of intestinal rotation for prompt diagnosis and timely intervention of this rare clinical anomaly without any complications.
Reference: J Med Case Reports