Lupiañez-Merly Camille, Torres-Ayala Stephanie C, Morales Lorena, Gonzalez Adel, Lara-Del Rio José A, Ojeda-Boscana Ivonne
Body Imaging Section, Department of Diagnostic Radiology, University of Puerto Rico School of Medicine, San Juan, Puerto Rico.
2 Department of Internal Medicine, Veteran Affairs Caribbean Healthcare System, San Juan, Puerto Rico.
Am J Case Rep. 2018 Apr 16;19:447-452. doi: 10.12659/ajcr.908276.
BACKGROUND Appendicitis is the most common cause of abdominal pain requiring emergent surgical intervention. Although typically presenting as right lower-quadrant pain, in rare cases it may present as left upper-quadrant pain secondary to abnormal position due to intestinal malrotation. Since atypical presentations may result in diagnostic and management delay, increasing morbidity and mortality, accurate and prompt diagnosis is important. Therefore, acute appendicitis should be considered in the differential diagnosis of left upper-quadrant abdominal pain. In this setting, medical imaging plays a key role in diagnosis. We report a case of a 13-year-old female with undiagnosed intestinal malrotation presenting with left-sided acute appendicitis. CASE REPORT A 13-year-old Hispanic female presented at the emergency room with anorexia and left upper-quadrant abdominal pain with involuntary guarding. The laboratory work-up was remarkable for elevated white blood cell count and elevated erythrocyte sedimentation rate. A nasogastric tube was placed and abdominal x-rays performed to rule-out bowel obstruction, showing distended bowel loops throughout all abdominal quadrants, with sigmoid and proximal rectal gas, raising concern for ileus rather than an obstructive pattern. Lack of symptomatic improvement prompted an IV contrast-enhanced abdominopelvic CT, revealing intestinal malrotation and with an inflamed left upper-quadrant appendix. Surgical management proceeded with a laparoscopic Ladd's procedure. CONCLUSIONS Acute appendicitis may present with atypical symptoms due to unusual appendix locations, such as in malrotation. Most cases are asymptomatic until development of acute complications, requiring imaging for diagnosis. Clinicians and radiologists should have a high index of suspicion and knowledge of its clinical presentations to achieve early diagnosis and intervention.
阑尾炎是需要紧急手术干预的腹痛最常见原因。虽然通常表现为右下腹疼痛，但在罕见情况下，由于肠旋转不良导致位置异常，可能表现为左上腹疼痛。由于非典型表现可能导致诊断和治疗延迟，增加发病率和死亡率，准确及时的诊断很重要。因此，在左上腹腹痛的鉴别诊断中应考虑急性阑尾炎。在这种情况下，医学影像学在诊断中起关键作用。我们报告一例13岁女性，因未诊断出的肠旋转不良而出现左侧急性阑尾炎。病例报告：一名13岁西班牙裔女性因厌食和左上腹腹痛伴不自主肌卫到急诊室就诊。实验室检查结果显示白细胞计数升高和红细胞沉降率升高。放置了鼻胃管并进行了腹部X线检查以排除肠梗阻，结果显示所有腹象限肠袢扩张，乙状结肠和直肠近端有气体，这引起了对肠梗阻而非梗阻性模式的担忧。症状无改善促使进行静脉注射造影剂增强的腹部盆腔CT检查，结果显示肠旋转不良和左上腹阑尾发炎。手术治疗采用腹腔镜Ladd手术。结论：急性阑尾炎可能因阑尾位置异常（如旋转不良）而出现非典型症状。大多数病例在出现急性并发症之前无症状，需要影像学检查来诊断。临床医生和放射科医生应高度怀疑并了解其临床表现，以实现早期诊断和干预。
