An exceptional cause of left lower quadrant abdominal pain

Abstract

Acute appendicitis is an exceptional cause of left lower quadrant abdominal pain. Computed tomography scan is the key to its diagnosis and helps to establish its early treatment. We present a case of a 35-year-old male patient who presented acute appendicitis with redundant and loosely attached cecum which was diagnosed based on his left lower quadrant abdominal pain.

Key Words: Abdominal pain; Left lower quadrant; Appendicitis; Cecum; Computed tomography scan; Surgery

TO THE EDITOR

Acute appendicitis remains an exceptional cause of left lower quadrant abdominal pain. We report a case of an otherwise healthy 35-year-old male who presented with a 6-h increasing abdominal pain located in the left lower quadrant. The patient had a low-grade fever (38.4) and physical examination demonstrated that he had rebound tenderness and guarding in the hypogastric and left paraombilical areas. Laboratory tests revealed mild left-shifted leucocytosis (11.8 109/L, neutrophils: 86%) and elevated C-reactive protein concentration (86.2 mg/L). According to the subtle presentation, an IV-injected and contrast-ingested computed tomography (CT) abdominal scanning showed a tubular, dilated, blind-ending and fluid-filled structure (Figure 1), strongly suggestive of acute appendicitis next to a midline-located cecum. The patient underwent appendectomy through a midline laparotomy. The appendix was acutely inflamed, while the cecum was redundant and loosely attached. Intestinal malrotation was excluded. The patient's postoperative course was uneventful.

Figure 1 Abdominal CT scan. A midline cecum (grey arrow) and dilated appendix with a thickened wall containing fecaliths consistent with acute appendicitis (white arrow).

Acute appendicitis remains an uncommon cause of left lower quadrant pain, leading to intestinal malrotation or situs inversus[1]. Such a clinical presentation is anecdotic in the absence of anatomic anomalies[2]. The exceptional mobility of the cecum in this case explains the left-sided symptoms. In the context of atypical acute abdominal pain, CT scan is helpful in reducing mortality and morbidity when its prompt and accurate diagnosis is established[3,4]. Actually, it is also useful in adopting the midline approach. Isolated acute appendicitis remains an exceptional cause of left lower quadrant pain which can be most accurately explored with abdominal CT scan.