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Left-sided Appendicitis

Left Sided Appendicitis

Left-sided appendicitis is an infrequent condition characterized by pain in the left lower quadrant caused by a very long or misplaced appendix vermiformis. This ailment is associated with situs inversus totalis or midgut malrotation. The appendix may also have other locations, such as mid-inguinal, subcecal, retrocecal, pre-ileal, post-ileal, meso-celiac, pelvic or subhepatic, but in left-sided appendicitis, it is more often located in the lower left quadrant.


Presentation

Left-sided appendicitis is a difficult diagnosis to establish due to the unusual presentation and is often delayed [1]. The disease has been described between the ages of 8 and 63 and affects men 1.5 times more often than women [2]. The presentation consists of periumbilical discomfort [3] followed by acute left lower quadrant pain and rebound tenderness. Clinical judgment is challenged, as many conditions cause pain in lower abdominal areas: sigmoid diverticulitis, hernias, enteritis, Meckel’s diverticulum, intestinal obstruction or volvulus, renal colic, pelvic inflammatory diseases, testicular torsion, ovarian diseases or mesenteric ischemia or adenitis [4] [5]. To make the clinical picture even more puzzling, patients with left-sided appendicitis may complain about bilateral or right-sided pain [6]. Right-sided pain in situs inversus is induced by the fact that the nervous system structures are not correspondingly transposed [7]. The physician should also conduct a thorough history inquiry, referring to certain diseases like Henoch-Schonlein purpura, diabetes mellitus, sickle cell anemia or epiploic appendagitis [8] in particular, all of these may present with abdominal pain. Scoring systems, such as the Ohmann, Eskelinen or Alvarado do exist and may be employed, but their power of predictability is less than perfect [9].

Fever
  • CASE REPORT: A 50-year-old man presented with fever and left lower abdominal pain. Physical examination revealed local tenderness over the left lower quadrant.[ncbi.nlm.nih.gov]
  • Case presentation A 46-year-old previously healthy male with four days of primarily left-sided abdominal pain, low-grade fevers, nausea and anorexia presented to the Emergency Department.[jmedicalcasereports.biomedcentral.com]
  • Physical examination reveals a low-grade fever (100.5 F; 38 C), pain on palpation at right lower quadrant (McBurney sign), and leukocytosis (12,000/microliter) with 85% neutrophils.[online.epocrates.com]
  • Seek prompt medical care if your pain is severe or is accompanied by a fever, severe or prolonged vomiting, bloody stools, urine changes, lightheadedness or fainting. Reviewed by: Mary D. Daley, MD[livestrong.com]
  • On physical examination he was normotensive (125/75 mmHg), had subfebrile fever (37.1 C), and localized tenderness at left lower quadrant. There was no abdominal defense. Complete blood count revealed a white blood cell count (WBC) of 17.500 /mm 3 .[causapedia.com]
Neonatal Intestinal Obstruction
  • Neonatal intestinal obstruction with isolated levocardia. J Pediatr Surg 2000;35:1115-6. 3. Akbulut S, Caliskan A, Ekin A, Yagmur Y. Left-sided acute appendicitis with situs inversus totalis: Review of 63 published cases and report of two cases.[mjdrdypu.org]
Left Lower Quadrant Pain
  • Left-sided acute appendicitis should be considered in the differential diagnosis of young patients presenting with left lower quadrant pain, in order to avoid delay in diagnosis and guide the surgical intervention.[ncbi.nlm.nih.gov]
  • The diagnosis of left lower quadrant pain is based on well-established clinical symptoms, physical examination and physician's experience.[ncbi.nlm.nih.gov]
  • The presentation consists of periumbilical discomfort followed by acute left lower quadrant pain and rebound tenderness.[symptoma.com]
  • Acute appendicitis is a rare cause of left lower quadrant pain. Situs inversus and malrotation of the midgut loop are two anatomic abnormalities that cause left sided appendix 2 .[causapedia.com]

Workup

The first step in establishing the left-sided appendicitis diagnosis is an attentive clinical examination, but this is often not revelatory. However, if the patient has situs inversus totalis, the clinician can obtain valuable hints regarding organ location using the classical methods: inspection, palpation, percussion, and auscultation. The electrocardiogram will demonstrate the right position of the heart, as will a simple posteroanterior chest radiography. An abdominal radiography will describe a right-sided gastric bubble in situs inversus. In situs solitus with midgut malrotation patients, the physician should order a barium enema in order to establish the position of the appendage, if clinical judgment dictates [1].

Imaging methods play key roles in the diagnosis algorithm, and ultrasonography, despite being operator dependent, is widely used. Abundant bowel gas or a large habitus causing a poor acoustic window can make examination difficult with this method. In uncertain cases, a computer tomography offers further information, with a general accuracy of 90-98% [2] [10]. Abdominal films are not usually indicated because they offer no relevant information in this instance. When the cause of the pain remains unknown, an emergency diagnostic laparoscopy may be ordered.

Blood workup in acute appendicitis will often show the presence of leukocytosis, this being the only contributory finding.

Dyslipidemia

Treatment

  • Treatment of incidentally discovered malrotation in asymptomatic patients older than 1–2 years of age remains somewhat controversial [ 5 , 7 ].[jmedicalcasereports.biomedcentral.com]
  • Peritonitis: Diagnosis and Treatment. Mayo Clinic . May 16, 2018. Appendicitis: Diagnosis and Treatment. Mayo Clinic . March 9, 2018. Appendectomy Indications. MedlinePlus. April 30, 2018. Shah SS, Gaffney RR, Dykes TM, and Goldstein JP.[everydayhealth.com]
  • Surgical treatment of malrotation after infancy: a population-based study.J Pediatr Surg.2005;40(1):285-9. Forrester MB,Merz RD. Epidemiology of intestinal malrotation, Hawaii, 1986-99.Paediatr Perinat Epidemiol.2003;17(2):195-200.[causapedia.com]
  • Up to now, surgical treatment has been guided by the experience from pediatric surgery, and Ladd's procedure has been the treatment of choice in adults with MMR.[jstcr.org]

Prognosis

  • The prognosis in patients with diverticulitis depends on the severity of the illness, the presence of complications, and the presence of any coexisting medical problems.[emedicine.medscape.com]
  • The appendicular artery is a single end artery closely applied to the wall distally, and secondary thrombosis is common giving rise to gangrene which explains the short progressive history (3–5 days) of appendicitis and the poorer prognosis with the artherosclerosis[intechopen.com]

Etiology

  • Although not very common, these etiologies should be considered while building a comprehensive differential diagnosis.[clinicaladvisor.com]
  • Thus, awareness of the multiple etiologies, common and uncommon, and their unusual and sometimes confounding presentations is critical for the Emergency Physicians and surgeon alike.[ispub.com]
  • If left lower quadrant pressure by the examiner leads only to left-sided pain or pain on both the left and right sides, then there may be some other pathologic etiology .[en.wikipedia.org]
  • Nonetheless, the clinical links for most etiologies have been reported well in the literature. Table 3 summarizes these etiological findings.[karger.com]
  • Porphyria Familial Hepatitis Acute adrenal insufficiency Mediterranean fever Cholecystitis Hematologic disorders Cholelithiasis Sickle cell anemia Splenic infarction Henoch-Schönlein purpura Rupture of the spleen Hemolytic uremic syndrome Pancreatitis Etiology[aafp.org]

Epidemiology

  • Epidemiology of intestinal malrotation, Hawaii, 1986-99.Paediatr Perinat Epidemiol.2003;17(2):195-200.[causapedia.com]
  • ., The Epidemiology of Appendicitis and Appendectomy in the United States. vol. 132, No. 5: 910-925 American Academy of Family Physicians. Acute Appendicitis: Review and Update.[emedicinehealth.com]
  • Diverticular disease as a chronic illness: evolving epidemiologic and clinical insights. Am J Gastroenterol . 2012 Oct. 107 (10):1486-93. [Medline] . Brandl A, Kratzer T, Kafka-Ritsch R, Braunwarth E, et al.[emedicine.medscape.com]
Sex distribution
Age distribution

Pathophysiology

  • Disconnect between incidence of nonperforated and perforated appendicitis: implications for pathophysiology and management. Ann Surg 2007;245:886–892. 7. Lee HY, Ha HI, Lee KS, Kim MJ, Lim HK.[clinicalultrasound.org]
  • Etiology and pathophysiology of diverticular disease. Clin Colon Rectal Surg . 2004 Aug. 17 (3):147-53. [Medline] . Matrana MR, Margolin DA. Epidemiology and pathophysiology of diverticular disease. Clin Colon Rectal Surg . 2009 Aug. 22 (3):141-6.[emedicine.medscape.com]
  • After giving background on the embryology and anatomy of the appendix as well as the pathophysiology, etiology, and clinical manifestations of appendicitis, we review the genitourinary simulations of appendicitis symptomatology with respect to the adrenal[karger.com]
  • Pathophysiology Clinically, abdominal pain falls into three categories: visceral (splanchnic) pain, parietal (somatic) pain, and referred pain. Visceral pain occurs when noxious stimuli affect a viscus, such as the stomach or intestines.[aafp.org]

Prevention

  • The location of her pain prevented correct clinical diagnosis, resulting in rupture and advanced disease.[casereports.in]
  • Seite 290 - Antibiotic prophylaxis for the prevention of bacterial infections in cirrhotic patients with gastrointestinal bleeding: A meta-analysis. Hepatology 1999; 29: 1655-61 6. ‎[books.google.de]
  • Can Appendicitis Be Prevented? There is no way to prevent appendicitis. But when kids get the right medical care quickly, doctors usually find and treat it without problems.[kidshealth.org]
  • Diagnostic laparoscopy can localize the exact position of appendix so that inappropriate incisions can be prevented, even if open appedicectomy is planned.[jemds.com]
  • As the causes aren't fully understood, there's no guaranteed way of preventing appendicitis. Who's affected? Appendicitis is a common condition. Around 40,000 people are admitted to hospital with appendicitis each year in England.[nhs.uk]

References

Article

  1. Ahmed J, Hossain G, Karim M, et al. Left sided acute appendicitis with situs inversus in an elderly - an unusual case. JCMCTA. 2007;18:29–31.
  2. Perera W, Hennessy O. Clinical Images. An unusual case of appendicitis. Am J Surg. 2010;199:e79–e81.
  3. Yang C, Liu H, Lin H, et al. Left-sided acute appendicitis: a pitfall in the emergency department. J Emerg Med. 2012;43(6):980-2.
  4. Cartwright S, Knudson M. Evaluation of acute abdominal pain in adults. Am Fam Physician. 2008;77:971–978.
  5. Nelson M, Pesola G. Left lower quadrant pain of unusual cause. J Emerg Med. 2001;20:241-5.
  6. Akbulut S, Ulku A, Senol A, et al. Left-sided appendicitis: review of 95 published cases and a case report. World J Gastroenterol. 2010;16:5598–602.
  7. Van Steensel C, Wereldsma J. Acute appendicitis in complete situs inversus. Neth J Surg. 1985;37(4):117-8.
  8. Sorser S, Maas L, Yousif E, et al. Epiploic appendagitis: the great mimicker. South. Med. J. 2009;102(12):1214-7.
  9. Tawk C, Zgheib R, Mehanna S. Unusual case of acute appendicitis with left upper quadrant abdominal pain. International Journal of Surgery Case Reports. 2012;3:399‐401.
  10. Hou SK, Chern CH, How CK, et al. Diagnosis of appendicitis with left lower quadrant pain. J Chin Med Assoc. 2005;68:599–603.

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Last updated: 2018-06-21 23:40