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Journal of Surgery & Transplantation Science

Cite this article: Rodrigues Buzatti KCL, e Silva Rodrigues BD, e Silva LC, da Silva RG (2017) Acute Appendicitis in the Left Upper Quadrant of the Abdomen: a Rare Location of a Common Inflammatory Disease of the Abdomen. J Surg Transplant Sci 5(3): 1061.

*Corresponding authorKelly Buzatti, School of Medicine/Hospital of Clinics, Federal University of Minas Gerais, Rua dos Otoni 735/1001 Santa Efigênia, Belo Horizonte – MG, CEP: 30150-270, Brazil, Tel: 55-313274-2588; Email:

Submitted: 20 November 2017

Accepted: 28 December 2017

Published: 31 December 2017

ISSN: 2379-0911

Copyright© 2017 Rodrigues Buzatti et al.

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Keywords• Acuteappendicitis• Appendectomy• Left-sided appendicitis• Acuteabdomen

Case Report

Acute Appendicitis in the Left Upper Quadrant of the Abdomen: A Rare Location of a Common Inflammatory Disease of the AbdomenKelly Cristine Lacerda Rodrigues Buzatti1,2*, Beatriz Deoti e Silva Rodrigues1, Luciana Costa e Silva1, and Rodrigo Gomes da Silva1,2

1Alpha Institute of Gastroenterology, Federal University of Minas Gerais, Brazil 2Rede Mater Dei de Saúde, Belo Horizonte, Brazil

Abstract

Introduction: The appendix is usually found in the right lower quadrant of the abdomen but its tip may vary in location such as in the pelvis or in the left side of the abdomen leading to atypical presentations of acute appendicitis. In this article, we present a rare case report of acute appendicitis in the left upper quadrant of the abdomen.

Case report: A 69-year-old previously healthy female patient attended to the emergency department complaining of abdominal pain in the left upper quadrant for about 36 hours, increase of white cell count (16 x 109/L) and C-reactive protein of about 200. Antibiotic therapy was immediately started due to the hypothesis of acute infectious disease of the abdomen. The abdominal ultrasound did not found the appendix and computed tomography (CT) scan of the abdomen initially reported diverticulitis as the diagnosis. In a further review of the CT scan images, the radiologist found the tip of the appendix in the left upper quadrant of the abdomen with a diameter of 10mm and surrounded by inflammatory signs. Laparoscopic appendectomy was performed and the patient was discharged home in the second postoperative day without surgical complications. Pathological examination confirmed acute appendicitis.

Conclusion: Although acute appendicitis is the most common acute surgical disease of the abdomen, some of its unusual presentations can be challenging. In this scenario, image exams, laparoscopy or open laparotomy may be necessary for early diagnosis.

leukocytosis and the retrocecal localization of the appendix close to the ureter may lead to urinary symptoms [6].

In unusual manifestations, acute appendicitis can be confused with cholecystitis, pyelonephritis or right colon diverticulitis when the abdominal pain is located in the right upper quadrant of the abdomen. But when localized in the left side, acute appendicitis can mimic diverticulitis or gynecological diseases.

Although clinical history, physical examination and laboratory tests can be enough for diagnosing, abdominal ultrasonography (US) is the first choice when complementary tests are needed [7]. The reporting of a thickened appendix (7 mm or more of diameter) and non-compressible luminal structure in the right lower abdominal quadrant suggests acute appendicitis [8]. Computed tomography (CT) scan should be performed when US did not find the appendix, for non-typical symptoms or for complicated cases [9].

Appendectomy is still the standard treatment for acute appendicitis and patients with prompt diagnosis of uncomplicated appendicitis can be discharged within 24 hours after surgical treatment [10,11].

ABBREVIATIONSUS: Ultrasonography; CT: Computed Tomography

INTRODUCTIONAcute appendicitis is the main cause of surgical abdominal

inflammatory disease with peak incidence between 10 and 30 years old [1,2].

The appendix is usually found in the right lower quadrant of the abdomen with average length of 9cm and localized in the convergence of the taenias in the cecum. The tip of the appendix may vary in its location leading to uncommon clinical presentations of acute appendicitis [3]. The appendix is located in the pelvis in up to 30% of the population and more rarely we may also find its tip in the left side of the abdomen when the cecum and ascending colon are unattached to the lateral peritoneum charactering the mobile cecum syndrome [4,5].

The typical clinical presentation of acute appendicitis initiates with diffuse abdominal pain followed by hyporexia and nausea. The pain is later located in the lower right quadrant of the abdomen where tenderness and defense may be found during physical examination. Some patients also develop fever and

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In this article, we present a rare case report of acute appendicitis in the left upper quadrant of the abdomen.

CASE PRESENTATIONA 69-year-old previously healthy Caucasian female patient

from Belo Horizonte (Brazil) attended to the emergency department with a 36-hour history of abdominal pain in the left upper quadrant, non-radiating and not related to food intake. She had nausea, vomiting and hyporexia but she denied any diarrhea, fever, dysuria or blood in the stool. There was no history of smoking, alcohol intake or family history of bowel disease. On the clinical examination, she had pain and abdominal tenderness in the left upper quadrant. There were no abnormalities in the rest of the physical examination. Laboratory tests showed an increase of white cell count (16 x 109/L) and C-reactive protein of about 200. Antibiotic therapy was immediately started due to the hypothesis of acute infectious disease of the abdomen.

The abdominal US did not found the appendix due to small bowel distention. Computed tomography (CT) scan of the abdomen and pelvis was performed and initially reported diverticulitis as diagnosis due to the finding of inflammatory changes near the left colon and a previous related colonoscopy reporting colonic diverticulosis. Another radiologist subsequently revised the CT scan and the new examination was suggestive of acute left-sided appendicitis rather than diverticulitis. The cecum was visualized in the left abdomen and the tip of the appendix was located in the left upper quadrant with a diameter of 10mm and the presence of inflammatory signs around it (Figure 1).

The patient was taken to the operation room for laparoscopic abdominal exploration, which confirmed left-sided appendicitis and localized peritonitis (Figure 2). Laparoscopic appendectomy (Figure 3) was performed and the cavity was washed with saline solution. The patient was discharged home in the second postoperative day and she did not have any surgical complications in the following weeks. Pathological examination confirmed acute appendicitis.

DISCUSSION We reported this unusual case of acute appendicitis mimicking

diverticulitis of the left colon. Although pelvic and left lower

abdominal pain are quite common in appendicitis, symptoms in the left upper quadrant of the abdomen are extremely rare [3].

Appendicitis and diverticulitis are common acute abdominal inflammatory diseases. Both of these inflammatory conditions need prompt diagnosis and early therapy with antibiotics, which may decrease the rates of morbidity and mortality. In this case report, the left-sided location of the abdominal pain, the previous colonoscopy reporting diverticulosis and the finding of inflammatory signs near the left colon suggested diverticulitis as the first diagnosis instead of appendicitis.

The diagnosis of acute appendicitis is clinical, but when the atypical manifestation occurs CT scan plays an important role in the rapid and valid diagnosis in such confusing and complicated cases of appendicitis or when diverticulitis is one of the possible hypotheses. In this case reported, the careful review of the images of the CT scan enabled the correct diagnosis since the US did not find the appendix.

CONCLUSIONIn conclusion, although acute appendicitis is a very common

inflammatory disease of the abdomen, some of its unusual presentations can be challenging and misdiagnosed. CT scan, laparoscopic approach or open laparotomy may be valuable diagnostic instruments in atypical clinical manifestation due to mobile cecum syndrome.

Figure 1 Computed tomography image of the tip of the appendix in the left upper quadrant of the abdomen (arrow).

Figure 2 Localized purulent peritonitis around the appendix during the laparoscopic approach.

Figure 3 Acute appendicitis findings in the appendix with edema and hyperemia.

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Rodrigues Buzatti KCL, e Silva Rodrigues BD, e Silva LC, da Silva RG (2017) Acute Appendicitis in the Left Upper Quadrant of the Abdomen: a Rare Location of a Common Inflammatory Disease of the Abdomen. J Surg Transplant Sci 5(3): 1061.

Cite this article

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