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].

• Pain

  The presentation consists of periumbilical discomfort followed by acute left lower quadrant pain and rebound tenderness. [symptoma.com]

  Fifty-nine patients had presented to the hospital with left lower, 14 with right lower and seven with bilateral lower quadrant pain, and seven subjects complained of left upper quadrant pain. [ncbi.nlm.nih.gov]

  The patient was asymptomatic during his life and was not diagnosed until the onset of acute pain. The location of her pain prevented correct clinical diagnosis, resulting in rupture and advanced disease. [casereports.in]

• Fever

  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]

  The first signs of appendicitis are often a mild fever and pain around the belly button. It might seem like just a stomachache. But with appendicitis, the pain usually gets worse and moves to the lower right side of the belly. [kidshealth.org]

  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]

  Fever is uncommon and most patients have had previous painful ovulation. In pelvic inflammatory disease, including salpingitis and tubo-ovarian abscess, there is a longer duration of symptoms, higher fever, greater leucocytosis and more pelvic pain. [surgwiki.com]

  […] if they can, it makes appendicitis unlikely) There is blood in the vomit, stool, urine or in vaginal discharge Urine goes brown (early sign of jaundice) There is systemic upset, such as shock (low blood pressure, fast heart rate, shortness of breath, fever [drmyhill.co.uk]

• Asymptomatic

  The majority of MMR in adults remains asymptomatic throughout life. [6] Adult MMR is rare with an incidence ranging from 0.0001 to 0.19% in asymptomatic adults. [6] There is no consensus on the management of asymptomatic MMR in adults. [jstcr.org]

  The true incidence of adults with asymptomatic malrotation remains difficult to accurately determine. [jmedicalcasereports.biomedcentral.com]

  When patients with asymptomatic undiagnosed gastrointestinal malrotation clinically present with abdominal pain, accurate diagnosis and definitive therapy may be delayed, possibly increasing the risk of morbidity and morality. [joms.rrmch.org]

  Presentation of intestinal malrotation in adults is mostly asymptomatic. Several classifications exist regarding the types of intestinal malrotation such as Balthazar and Stringer. [casereports.in]

  DISCUSSION The patient in this case report with an intestinal malrotation had been asymptomatic until the recent onset of the acute abdominal pain. [latunisiemedicale.com]

• Anemia

  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 in particular, all of these may present with abdominal pain. [symptoma.com]

  Family History A family history of sickle cell anemia or cystic fibrosis may indicate the diagnosis. The patient's ethnic background is important because sickle cell anemia is most common in blacks of African origin. [aafp.org]

• Chills

  Knife-like, stabbing pain that wraps around the lower stomach area and is accompanied by nausea, vomiting, fever and chills could be a sign of kidney stones, Dr. Glatter says. If that's the case, get to your doctor as soon as possible. [womansday.com]

  High fever with chills is typical of pyelonephritis and pneumonia. 12 Tachycardia and hypotension suggest hypovolemia. If a postmenarcheal girl is in shock, ectopic pregnancy should be suspected. [aafp.org]

• Sneezing

  Appendicitis pain sharpens over several hours and can worsen during movement, deep breaths, coughing, and sneezing. [everydayhealth.com]

• Abdominal Pain

  In addition, this case stressed the value of laparoscopy in daily practice to evaluate patients with atypical abdominal pain. [ncbi.nlm.nih.gov]

  But, when a patient presents with left sided lower abdominal pain, the first suspicion will be of diverticulitis. [casereports.in]

  Case Report A 63-year-old man presented with 2-day history of loss of appetite and abdominal pain located at left lower quadrant. He had no prior history of significant abdominal pain or any chronic disease. [causapedia.com]

  Acute abdominal pain in children presents a diagnostic dilemma. Although many cases of acute abdominal pain are benign, some require rapid diagnosis and treatment to minimize morbidity. Numerous disorders can cause abdominal pain. [aafp.org]

  Left side abdominal pain largely occurs due to trapped gas. Abdominal Aneurysm : Any leakage of blood in the aorta inside the digestive system causes abdominal aortic aneurysm. This condition can cause intense pain in the left side of the abdomen. [diseasespictures.com]

• Lower Abdominal Pain

  We present a case of 14-year girl with left-sided acute appendicitis who presented with lower abdominal pain. Midgut malrotation occurs at a rate of 1 in 500 live births. [ncbi.nlm.nih.gov]

  Commonly, for a right lower abdominal pain first disease suspected is appendicitis. If, pain arises from similar location in the left side, appendicitis is often not considered. [clinicianonnet.blogspot.com]

  A 40 year old man was admitted with history of acute left lower abdominal pain, with uncontrolled diabetic keto-acidosis. Clinically, he was diagnosed as acute diverticulitis with localized peritonitis. [journalofmas.com]

• Diarrhea

  Food Poison : Depending on the nature of poison the digestive system can produce symptoms of diarrhea, fever, nausea and severe abdominal pain. [diseasespictures.com]

  See your doctor if your LLQ pain lasts more than a few days, especially if it is accompanied by constipation, diarrhea, weight loss, vaginal discharge or nausea. [livestrong.com]

  This pain often begins around the belly button area and moves to the lower abdomen, gets worse with time, and could also cause vomiting, diarrhea, or constipation. [womansday.com]

  The inflammation of diverticulitis can eventually result in a bowel obstruction, which may cause constipation, thin stools, diarrhea, abdominal swelling or bloating, and abdominal pain. [webmd.com]

  […] begins around your navel and often shifts to your lower right abdomen Pain that worsens if you cough, walk or make other jarring movements Nausea and vomiting Loss of appetite Low-grade fever that may worsen as the illness progresses Constipation or diarrhea [mayoclinic.org]

• Left Lower Quadrant Pain

  However, acute appendicitis presenting with left lower quadrant abdominal pain is extremely rare. [ncbi.nlm.nih.gov]

  62% of the patients presented with left lower quadrant pain, 14% with right lower quadrant pain and 7% with bilateral pain. [mjdrdypu.org]

  Although it is a rare cause of left lower quadrant pain, left-sided acute appendicitis should be considered by emergency room physician and radiologists in the differential diagnosis of abdominal pain. [causapedia.com]

  Thirty-eight patients had applied to the hospital with left lower quadrant pain, 12 with right and 6 with bilateral lower quadrant pain. [link.springer.com]

• Constipation

  CONSTIPATION Acute constipation usually has an organic cause (e.g., gastroenteritis, appendicitis), while chronic constipation usually has a functional cause (e.g., low-residue diet). [aafp.org]

  See your doctor if your LLQ pain lasts more than a few days, especially if it is accompanied by constipation, diarrhea, weight loss, vaginal discharge or nausea. [livestrong.com]

  Constipation: acute constipation usually has an organic cause (eg, gastroenteritis). [ 1 ] Again, it should be a diagnosis of exclusion. [patient.info]

  This pain often begins around the belly button area and moves to the lower abdomen, gets worse with time, and could also cause vomiting, diarrhea, or constipation. [womansday.com]

  Constipation : Accumulation of feces in the large intestine occurs due to regular constipation. This condition can cause considerable pain in the abdomen. [diseasespictures.com]

• Arthralgia

  Clues to the differential diagnosis include recent sore throat (mesenteric adenitis), previous episode (Crohn’s disease), weight loss (Crohn’s disease, caecal carcinoma), dyspepsia (cholecystitis, perforated ulcer), arthralgia ( Yersinia enterocolitica [intechopen.com]

• Fear

  Traditionally, the use of analgesics is discouraged in patients with abdominal pain for fear of interfering with accurate evaluation and diagnosis. [aafp.org]

• Pelvic Pain

  The separate general articles Abdominal Pain, Abdominal Examination and Pelvic Pain have some overlap with this article. Left iliac fossa (LIF) pain may occur due to a self-limiting condition but may also be a sign of a medical/surgical emergency. [patient.info]

  The pain is not as severe as that associated with abdominal or pelvic appendicitis and the pain rarely localises well to the right iliac fossa. [surgwiki.com]

  Pelvic Inflammatory Disease Acute pelvic inflammatory disease can present with fever and lower abdominal pain, similar to that of acute appendicitis. Neisseria gonorrhoeae and Chlamydia trachomatis are the most commonly implicated organisms. [jaocr.org]

• Flank Pain

  Small stone in right ureter (arrow) causing right flank pain. Urolithiasis Urolithiasis often causes flank pain, but an ureteral stone (arrowhead) may occasionally present with clinical signs simulating appendicitis, cholecystitis or diverticulitis. [radiologyassistant.nl]

  Other causes [ 4 ] Abdominal aortic aneurysm : this can present with atypical symptoms resembling renal colic or diverticular disease rather than the classic back or flank pain. Do not forget this differential diagnosis. [patient.info]

  Symptoms include abdominal pain, flank pain, and high fever. Perinephric fluid is typically visible through ultrasonography, but CT scan may be required to identify the ruptured appendix. [karger.com]

• Dyspareunia

  Patients may have additional symptoms relating to the urogenital tract, including dysuria, dyspareunia, and vaginal discharge. [jaocr.org]

• Dysmenorrhea

  […] the lung and the abdomen. 1 View/Print Table TABLE 1 Causes of Acute Abdominal Pain in Children Gastrointestinal Genitourinary causes Drugs and toxins causes Urinary tract infection Erythromycin Gastroenteritis Urinary calculi Salicylates Appendicitis Dysmenorrhea [aafp.org]

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.

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]

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]

Outpatient treatment of patients with uncomplicated acute diverticulitis. Colorectal Dis. 2010 Oct. 12 (10 online):e278-82. [Medline]. Sanchez-Velazquez P, Grande L, Pera M. Outpatient treatment of uncomplicated diverticulitis: a systematic review. [emedicine.medscape.com]

In the absence of complications, treatment includes antibiotics and supportive measures. [jaocr.org]

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]

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]

G., et.al., 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]

Epidemiology of intestinal malrotation, Hawaii, 1986-99.Paediatr Perinat Epidemiol.2003;17(2):195-200. [causapedia.com]

Journal Journal ID (nlm-ta): Pan Afr Med J Journal ID (publisher-id): pamj Title: The Pan African Medical Journal Publisher: African Field Epidemiology Network ISSN (Print): 1937-8688 ISSN (Electronic): 1937-8688 Publication date Collection: 2010 Publication [scienceopen.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]

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]

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]

Antibiotics are used before and after an appendectomy to prevent wound infections. [everydayhealth.com]

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