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Journal of the Korean Society of Coloproctology 2008;24:219-222 DOI: 10.3393/jksc.2008.24.3.219
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Acute Perforated Appendicitis in a Patient with Nonrotation of the Midgut: A Case Report Department of Surgery, Postgraduate School of Medicine, Gyeongsang National University, Jinju, Korea
Seong-Jun Park, M.D., Young-Tae Ju, M.D., Chi-Young Jeong, M.D., Eun-Jung Jung, M.D., Young-Joon Lee, M.D., Soon-Chan Hong, M.D., Woo-Song Ha, M.D., Soon-Tae Park, M.D., Sang-Kyung Choi, M.D.
The presence of a malrotation of the midgut in adults is identified in asymptomatic patients most commonly as an incidental finding during a workup for an unrelated disease. We report here a rare case of acute perforated appendicitis in a patient with nonrotation of the midgut. A 28-year-old man was referred to our hospital with lower abdominal pain. The radiological examination, including abdominal computed tomography, ultrasonography, an upper gastrointestinal series, and a barium enema, revealed acute perforated appendicitis accom panied by nonrotation of the midgut. Emergency surgery revealed a complicated appendix located in the middle area of the lower abdomen with a periappendiceal abscess and nonrotation of the midgut. An ileocecal resection was performed with no postoperative complication. In this case, the atypical position of the appendix led to confusion regarding the diagnosis and to a more invasive surgical intervention. J Korean Soc
testinal nonrotation results from failure during the early second stage of embryonic development.3 By contrast, acute appendicitis is a common clinical problem in both adults and children. Diagnosis of appendicitis is based on history and physical examination. However, an atypical location of the appendix can lead to an incorrect diagnosis and result in appendiceal perforation. We report a rare case of acute perforated appendicitis in a patient with nonrotation of the midgut.
CASE REPORT A 28-year-old man was referred to our hospital with lower abdominal pain. He presented with a two-week his-
Coloproctol 2008;24:219-222
tory of epigastric and lower abdomen pain associated with
Key Words: Appendicitis, Nonrotation of the midgut
nausea and vomiting that had not improved with medical
treatment. On admission, he had a blood pressure of 100/80 mmHg, a heart rate of 90/beats/min and a temper-
INTRODUCTION
ature of 36oC. The laboratory study showed an elevation in the white blood cell count to 17,170/mm3. Physical ex-
A congenital abnormality of the midgut rotation most
amination revealed tenderness with muscle rigidity in the
commonly produces clinical manifestations in infants and
lower abdomen. A plain abdominal X-ray showed a nor-
children, but only rarely in adults.1 For adult patients,
mal gas pattern. However, abdominal computed tomog-
most cases of malrotation are identified in asymptomatic
raphy (CT) and ultrasonography (US) demonstrated a per-
patients and are detected incidentally during a workup for
forated appendix with a complex abscess cavity at the in-
unrelated disease later in life.2 The presence of an in-
fra-umbilical area (Fig. 1, 2) and nonrotation of the midgut. An upper gastrointestinal series and a barium enema showed that the small bowel was mainly on the right
Received February 9, 2007, Accepted April 18, 2008 Correspondence to: Sang Kyung Choi, Department of Surgery, Postgraduate School of Medicine, Gyeongsang National University, 90, Chilam-dong, Jinju 660-702, Korea Tel: +82-55-750-8096, Fax: +82-55-750-8732 E-mail:
[email protected]
side of the abdominal cavity and that the large bowel was on the left side, suggesting nonrotation of the midgut (Fig. 3, 4).
219
220 Journal of the Korean Society of Coloproctology: Vol. 24, No. 3, 2008
Fig. 1. A computed tomography scan showed a perforated appendix with a complex abscess cavity at the infraumbilical area. Fig. 3. Upper gastrointestinal study showed the small bowel was mainly on the right side of the abdominal cavity and no duodenojejunal flexure of Treitz is formed.
Fig. 2. An ultrasonography showed thickened appendix with periappendiceal abscess formation.
Emergency surgery was performed with the diagnosis of acute perforated appendicitis in addition to nonrotation of the midgut. After induction of general anesthesia, a
Fig. 4. Barium enema showed that the large bowel was on the left side and ascending colon passes upward on the left of midline.
lower midline incision was made. During the laparotomy, we found nonrotation of the midgut. The small bowel was
scess with adhesions (Fig. 5). An ileocecal resection was
found mainly to the right side of the midline and the co-
performed. After the abdominal cavity was washed, a
lon to the left side. The first and the second parts of duo-
drainage tube was inserted, and the abdomen was closed.
denum were in their normal positions, but the third and
The histological findings confirmed the clinical diagnosis.
the fourth parts were further down than normal (Fig. 5).
The patient recovered and was discharged without post-
As a result, the perforated appendix was located in the
operative complication.
middle area of the lower abdomen. We could not identify the base of the appendix because of severe inflammation of the cecum and the presence of a periappendiceal ab-
Park SJ, et al. Acute Perforated Appendicitis in a Patient with Nonrotation of the Midgut: A Case Report 221
artery (SMA) and dislocation of the superior mesenteric vein lying to the left of the SMA.13 A rotational abnormality is suspected at laparotomy if 1) abnormal peritoneal bands develop from the ileum or right colon to the parietal peritoneum or to the duodenum 2) the duodenum and/or upper jejunum is fixed to the cecum or right colon 3) the entire duodenum, particularly the third and the fourth portions, is visualized at the base of the mesentery of the transverse colon and 4) the cecum or the duodenum has an abnormal position or mobility along the right gutter.3 Fig. 5. An operation view of severe inflammation of the cecum and periappendiceal abscess with adhesion (white arrow: cecum).
Even though computed tomography is enough for diagnosis, we carried out additional examinations, such as a barium enema and an upper gastrointestinal study, because we wanted to determine the abnormal positions of the duodenum and the cecum and because we had plenty
DISCUSSION
of time before the operation to prepare for the operation. The midgut forms a ventral U-shaped umbilical loop of the gut, the midgut loop, by the fifth week during em-
The barium enema and the upper gastrointestinal study confirmed our diagnosis.
bryological development; the so-called physiological um-
A difficulty in diagnosing appendicitis may occur as a
bilical herniation occurs at the beginning of the sixth
result of the abnormal location of the intestine along with
week. During the tenth week, the primary intestinal loop
nonrotation. This condition can cause confusion and
o
rotation.
misdiagnosis. In our case, the correct diagnosis was made
Nonrotation arises when the primary intestinal loop fails
because of immediate radiological examination, which
undergoes
a
total
270
counterclockwise
o
to undergo the normal 180 counterclockwise rotation as 4,5
was followed with emergency surgery. Therefore, the dif-
However, it is
ferential diagnosis of acute abdominal pain should include
not clear what prevents normal rotation, which is detected
rotational anomalies.14 Surgery for adult patients with
in 0.2% to 0.5% of the adult population, but is clinically
nonrotation and other inflammatory diseases is generally
it is retracted into the abdominal cavity.
6
significant in only a minority of cases.
the accepted approach for eradication of inflammation
Intestinal nonrotation in adults may be discovered upon
whereas an isolated nonrotation is not necessarily
laparotomy for acute small bowel obstruction or other
repaired.8,15 In our case, we did not repair the nonrotation
conditions, such as a peptic ulcer, appendicitis, regional
as there was no problem associated with the nonrotation.
1,7-9
In most adult pa-
In conclusion, physicians should consider abnormalities
tients, nonrotation occurs as an isolated entity whereas in
in the rotation of the intestine in the differential diagnosis
newborns, there is about a 70 percent incidence of other
of patients with an acute abdomen. The appropriate radio-
ileitis and Meckel’s diverticulum.
10,11
congenital anomalies.
The important role that radiological examination plays
logical examinations should be performed to confirm of the diagnosis.
in the diagnosis of anomalies of midgut rotation has been demonstrated. A barium enema may show the entire colon and ileocecal valve lying to the left of the midline, and an upper gastrointestinal study may reveal that the duodenojejunal junction is identified to the right of the vertebral bodies.
1,12
Computed tomography can reveal a whirl-like
pattern of bowel loops encircling the superior mesenteric
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Harder F. Acute and chronic presentation of intestinal nonrotation in adults. Dis Colon Rectum 1994;37:192-8. Larsen WJ. Human Embryology. 2th ed. New York: Churchill-Livingstone; 1997. p. 240-9. Larsen WJ. Human Embryology. 2th ed. New York: Churchill-Livingstone, 1997. p. 198-200. Estrada RL. Abnormalities of Intestinal Rotation and Fixation. Springfield: Charles C Thomas; 1958. Gohl ML, DeMeester TR. Midgut nonrotation in adults. An aggressive approach. Am J Surg 1975;129:319-23. Harvey JS, Giles GR. Associated midgut malrotation and Meckel’s diverticulum presenting in adult life. Br J Surg 1974;61:157-8. Fieber SS. Malrotation of the intestine with regional ileitis. Am J Surg 1954;88:510-2. Powell DM, Othersen HB, Smith CD. Malrotation of the intestines in children: the effect of age on presentation and therapy. J Pediatr Surg 1989;24:777-80. Fisher JK. Computed tomographic diagnosis of volvulus in intestinal malrotation. Radiology 1981;140:145-6. Hian TW. Malrotation of the midgut. Radiol Clin Biol 1972;41:413-21. Nichols DM, Li DK. Superior mesenteric vein rotation: a CT sign of midgut malrotation. AJR Am J Roentgenol 1983;141:707-8. Sato H, Fujisaki M, Takahashi T, Maruta M, Maeda K, Kuroda M. Mucinous cystadenocarcinoma in the appendix in a patient with nonrotation: report of a case. Surg Today 2001;31:1012-5. Rees JR, Redo SF. Anomalies of intestinal rotation and fixation. Am J Surg 1968;116:834-41.
국문 초록 중간장관의 비회전 환자에서 발생한 급성 천공성 충수돌기염: 증례보고 경상대학교 의학전문대학원 외과학교실 박성준ㆍ주영태ㆍ정치영ㆍ정은정ㆍ이영준 홍순찬ㆍ하우송ㆍ박순태ㆍ최상경
성인에서 중장의 이상회전은 대부분 증상이 없다가 관련이 없는 질환에 대한 검사 중에 우연히 발견된다. 우리는 중장의 이상회전을 가진 환자를 급성 천공성 맹장염으로 치료한 경험을 보고하고자 한다. 28세된 남자 환자가 하복부 통증을 주소로 본원으로 내원하 였다. 복부 컴퓨터 단층 촬영과 초음파 검사, 상부 위 장관 조영술, 바륨 관장 등의 방사선학적 검사를 통해 서 중장의 비회전을 동반한 급성 천공성 충수염을 진 단받았다. 응급 수술 중 하복부의 중간 지점에 위치한 합병된 충수를 발견할 수 있었고, 충수 주위에는 농양 을 동반하고 있었으며 중장이 비회전된 소견을 보였 다. 회맹장절제술을 시행하였고 수술 후 합병증 없이 퇴원하였다. 이 경우, 환자는 충수의 비정형적 위치 때 문에 여러 병원을 거치는 과정에서 진단이 늦어졌으 며 결국 더 침습적인 수술을 하게 되었다. 비록 매우 드문 질환이긴 하지만 임상에서 이런 가능성을 항상 고려한다면 같은 질환을 가진 환자를 만났을 때 더 빠 른 진단과 더 나은 치료가 가능할 것으로 생각된다. 중심단어: 충수돌기염, 중간장관의 비회전
