Left sided appendicitis with situs inversus totalis: an unusual cause of acute left lower quadrant abdominal pain
Abstract
To the Editor The most common cause of abdominal pain which requires surgery is appendicitis 1 Although acute lower quadrant abdominal pain has various causes related to gynecological genitourinary and gastrointestinal systems appendicitis is usually suspected in patients presenting with right lower quadrant pain Appendicitis may present with extraordinary signs and localization though rarely It may cause complications which may lead to death because of delayed diagnosis especially in children 2 Therefore rare clinical conditions of appendicitis should be known well especially by physicians who work in pediatric emergency departments In this article a case with situs inversus totalis SIT and appendicitis is presented and clinical and radiologic findings and treatment approaches are discussed in appendicitis with an atypical localization An 11 year old male patient presented to our emergency department with complaints including left lower quadrant pain nausea vomiting and loss of appetite lasting for the last 4 days Treatment for urinary tract infection was arranged in an external center and the patient rsquo;s complaints did not recover in the follow up On physical examination ldquo;defence rdquo; ldquo;rebound rdquo; and tenderness were found in the left lower quadrant In addition the apical heart beat was found to be localized in the right side Laboratory findings were as follows: WBC:20 800 mm3 N:4800 10800 serum C reactive protein CRP : 2 97 mg dL N:0 0 8 neutrophil percentage: 90 2 N:43 65 Left shift was present The cardiac apex was observed to be in the right side on antero porterior chest graphy and gastric fundus air shadow was observed to be in the right side on direct abdominal radiography in the standing position This finding was confirmed with dextrocardia found on echocardiography Abdominal ultrasonography showed that the liver was localized in the left and the spleen was localized in the right side A diagnosis of situs inversus totalis was made Findings compatible with incompressible appendicitis were present in the left lower quadrant; the caecum and surrounding tissues were edematous Pericecal fluid was present Laparotomy was performed by left Mc Burney incision It was observed that the appendix was perforated in the tip Appendectomy and drenaige were performed The patient was discharged on the 5th day after the operation without any problem Abdominal pain constitutes 6 5 of all presentations to the emergency department 3 A diagnosis can not be made in 21 of these patients 3 In children the diagnosis of appendicitis is generally more difficult compared to adults and a wrong diagnosis is made in 15 of the patients with appendicitis in the childhood age group 4 5 Therefore all frequent and rare causes should be considered in the evaluation of children presenting with abdominal pain Abnormalities including intestinal malrotation mobile cecum and SIT may result in left sided appendicitis 1 6 7 In situs inversus totalis all intrathoracic and abdominal organs are localized completely in the opposite side Kartagener syndrome which is characterized by bronchiectasia paranasal sinuzitis and SIT observed in 15 of the patients with SIT was excluded in our patient 8 While the appendix is localized in the left lower quadrant in patients with situs inversus totalis it can be localized in any quadrant in patients with malrotation and mobile cecum Collins et al 7 reported the prevalence of left sided appendicitis to be 0 04 and the prevelance of association of SIT and left sided appendicitis to be 0 016 Less than 100 cases have been reported in the literature 6 The diagnosis of left sided appendicitis is based on physical examination Antero posterior chest graphy and echocardiography are helpful radiologic investigations in the diagnosis of SIT Direct abdominal radiography in the standing position abdominal ultrasonography and computarized tomography are helpful radiologic investigations in the diagnosis of both SIT and appendicitis 1 Laporoscopy which has started to be used frequently in recent years is important both in the diagnosis and surgical treatment of cases of appendicitis accompanied by SIT 1 6 Appendicitis is a pathology which has a high morbidity and mortality rate especially in children when the diagnosis is delayed Therefore appendicitis with a different localization should be considered when extraordinary clinical findings are present in patients presenting to pediatric emergency departments with abdominal pain Ad shy;dress for Cor shy;res shy;pon shy;den shy;ce: Hüseyin Kılınçaslan MD Bezmialem Foundation University Department of Pediatric Surgery İstanbul Turkey E mail: hkilincaslan@gmail com Re shy;cei shy;ved: 02 28 2012 Ac shy;cep shy;ted: 05 14 2012 References 1 Hou SK Chern CH How CK Kao WF Chen JD Wang LM Huang CI Diagnosis of appendicitis with left lower quadrant pain J Chin Med Assoc 2005; 68 12 : 599 603 2 Wong CS Nagvi SA Appendicular perforation at the base of the caecum a rare operative challenge in acute appendicitis a literature review World J Emerg Surg 2011; 6: 36 3 Hastings RS Powers RD Abdominal pain in the ED: a 35 year retrospective Am J Emerg Med 2011; 29 7 : 711 716 4 Chang YJ Chao HC Kong MS Hsia SH Yan DC Misdiagnosed acute appendicitis in children in the emergency department Chang Gung Med J 2010; 33 5 : 551 557 5 Graff L Russell J Seashore J Tate J Elwell A Prete M Werdmann M Maag R Krivenko C Radford M False negative and false positive errors in abdominal pain evaluation: failure to diagnose acute appendicitis and unnecessary surgery Acad Emerg Med 2000; 7 11 : 1244 1255 6 Akbulut S Ulku A Senol A Tas M Yagmur Y Left sided appendicitis: review of 95 published cases and a case report World J Gastroenterol 2010; 16 44 : 5598 5602 7 Collins DC 71 000 human appendix specimens a final report summarizing forty years rsquo; study Am J Proctol 1963; 14: 265 281 8 Swartz MN Bronchiectasis In: Fishman AP ed Fishman rsquo;s pulmonary diseases and disorders 3rd ed Newyork: McGraw Hill Comp 1998: 2045 2070
Keywords
Sol yerleşimli apandisit ile situs inversus totalis birlikteliği: akut sol alt kadran karın ağrısının nadir bir sebebi
Öz
Cerrahi gerektiren en sık karın ağrısı nedeni apandisittir (1). Çocukluk yaş grubunda akut alt kadran ağrısının jinekolojik, genitoüriner ve sindirim sistemi ile ilgili çeşitli nedenleri olmasına rağmen, apandisitten genellikle sağ alt kadran ağrısı ile başvuran hastalarda şüphelenilir. Apandisit, nadir de olsa sıra dışı bulgular ve yerleşimle karşımıza çıkabilir. Özellikle çocuklarda geç tanı konulması nedeniyle ölüme kadar gidebilen komplikasyonlara neden olabilir (2). Bu yüzden apandisitin seyrek görülen klinik durumlarının özellikle çocuk acil servisinde çalışan hekimlerce iyi bilinmesi gerekir. Bu yazıda, situs inversus totalis (SİT) ve apandisitli bir olgu sunularak atipik yerleşimli apandisit olgularındaki klinik ve radyolojik bulgular ve tedavi yaklaşımı tartışılmıştır.
Anahtar Kelimeler
