The suprising stories of the acute abdomen:Tosion of the appendix vermiformis

Abstract

Acute appendicitis is the most common cause of acute abdominal pain needing surgical treatment. However, it can be clinically and radiologically mimicked by other conditions, some of them with an extremely rare occurrence. A two year old boy presented to our hospital with a history of abdominal pain and vomiting in the last 48 hours. On physical examination, the patient was found to be dehydrated, with a dry mouth and a white-coated tongue. Tenderness was noted throughout the entire abdomen, with rigidity and guarding, especially in the right lower quadrant. Laboratory results showed an elevated Creactive protein level of 50.2 mg/L and a white blood cell count of 25,800/μL. Under the suspicion of acute complicated appendicitis, emergency McBurney laparotomy was performed. Operative findings revealed an enlarged, dark purple, congested appendix, twisted 720° around its base at the cecum in the anticlockwise direction. There was no evidence of perforation. A typical appendectomy was performed. The postoperative course was uneventful and the patient was discharged home on the fourth post-operative day. Microscopic examination confirmed the hemorrhagic infarction and ischemic necrosis of the appendix, followed by an inflammatory reaction caused by the torsion. To our knowledge only 22 cases of torsion of the vermiform appendix in children have been reported in literature, with our case being the 23rd. Though extremely rare, it should be considered as a potential diagnosis in patients presenting with right lower abdominal pain. Histopathology is crucial in differentiating primary from secondary causes of appendicular torsion.