Left sided appendicitis.

Abstract

A 67 year old female presented with a 3 day history of suprapubic pain, nausea, dysuria and dyspnoea. The pain had progressively worsened and localized in the suprapubic region but was also present in the periumbilical region and both upper quadrants. She had a mild fever (37.6°C). Her background history included T1N0 mid-rectal cancer which had been treated by laparoscopic anterior resection and temporary loop ileostomy (with no bowel adhesions noted at time of reversal or subsequent surgery) 5 years prior to presentation. On examination, the patient had a soft abdomen with suprapubic and left sided tenderness. Urine dipstick showed trace protein, while blood tests demonstrated a mild neutrophilia (white cell count 11.5 × 109/L, neutrophils 10.5 × 109/L). A portal-venous phase abdominal CT demonstrated a thickened appendix in the left mid abdomen, which was arising from an abnormally positioned caecum, located adjacent to the descending colon (see Fig. 1). There was no volvulus. Mesenteric thrombosis was present in the ileocolic mesentery. Laparoscopic appendectomy was performed. A redundant caecum and associated necrotic appendix was found in the left mid abdomen. The peritoneal cavity was free of adhesions apart from a small omental adhesion to the umbilicus and there was no volvulus and no internal hernia. Entry had been via periumbilical open cut down technique and, under direct vision, a 10 mm suprapubic port was placed and a 5 mm port used in the left lower quadrant to facilitate operative access. The patient was treated with anticoagulation post-operatively, for what was surmised to be thrombosis secondary to inflammation and a ‘kinking effect’ in mesenteric blood vessels presumably related to the malposition of the redundant caecum. The vermiform appendix has multiple described anatomical positions. Although it is certain that the appendix is attached to the base of caecum, its final position can vary based on embryological differences or occasionally as a consequence of previous surgery. Appendicitis pain is typically generalized abdominal pain progressively localizing to the RLQ, when the appendix irritates parietal peritoneum. Abnormal positions of the appendix or its the tip may complicate the diagnosis as the site of pain varies, and the sites of migration of pain is likely to become atypical. Less common presentations of appendicitis include right and left upper quadrant pain. Right upper quadrant pain is commonly a result of caecal malposition, which has been reported to be present in 6% of patients in some studies.1 At the end of 10 week of intrauterine life, the caecum is in the subhepatic region temporarily and if arrest of caecum occurs this is generally asymptomatic and diagnosed incidentally.2 Other intestinal anatomical abnormalities as a result of congenital malrotation – including those associated with dextrocardia and situs inversus – may result in patients presenting with left upper quadrant pain with a left-sided appendix .3-5 Internal hernia can cause bowel malposition in a variety of locations. One systematic review reported that approximately 0.5% of patients developed internal hernia after laparoscopic colorectal resection.6 Malposition of the caecum would however be unlikely if only the left colon and rectum are mobilized in colorectal surgery, as occurred in this case. Mesenteric thrombosis is well recognized to occasionally occur secondary to an intra-abdominal inflammatory focus – including appendicitis7 – as a result of disruption of Virchov's triad. In the reported case, the caecum was malpositioned due to redundancy rather than embryological malrotation or previous surgery, which has only rarely been reported previously and not, to our knowledge, in association with mesenteric thrombosis. The case highlights that acute appendicitis should be one of the differential diagnoses for patients presenting with an acute abdomen, regardless of locations. Modern imaging is very helpful in securing a diagnosis and laparoscopic technique, with the potential to alter standard port position based on imaging and operative findings, is an advantageous approach. The patient has signed consent to publication form and the form is held by the treating institution. Open access publishing facilitated by The University of Auckland, as part of the Wiley - The University of Auckland agreement via the Council of Australian University Librarians. Serena Peng – literature review, write up, submission, image formating. M Biggar – senior author, clinical ownership/direction, literature review input, write up outline planning & editing.