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CASE REPORT

A left-sided periappendiceal abscess in an adult with intestinal

malrotation

Min Ro Lee, Jong Hun Kim, Yong Hwang, Young Kon Kim

Min Ro Lee, Jong Hun Kim, Yong Hwang, Department of this disease when treating adult patients with abdominal
Surgery, Chonbuk National University Medical School, San 2-20 pain because diagnosis of intestinal malrotation can be dif-
Geumam-dong, Deokjin-gu, Jeonju 561-756, South Korea ficult. The present report details an unusual case of a left-
Min Ro Lee, Jong Hun Kim, Research Institute of Clinical
Medicine, Chonbuk National University Medical School, San
sided periappendiceal abscess with intestinal malrotation
2-20 Geumam-dong, Deokjin-gu, Jeonju 561-756, South Korea in an adult who presented with a painful mass in the left
Young Kon Kim, Department of Diagnostic Radiology, Chonbuk lower quadrant.
National University Medical School, San 2-20 Geumam-dong,
Deokjin-gu, Jeonju 561-756, South Korea
Correspondence to: Professor Jong Hun Kim, MD, PhD, CASE REPORT
Department of Surgery, Chonbuk National University Medical A 43-year-old man with no previous abdominal complaints
School, San 2-20 Geumam-dong, Deokjin-gu, Jeonju 561-756,
South Korea. kimjhun@chonbuk.ac.kr
presented to the emergency room of our hospital with a
Telephone: +82-63-2501570 Fax: +82-63-2716197 2-wk history of a painful mass in the left lower quadrant.
Received: 2006-03-02 Accepted: 2006-04-21 Previously, his physician had administered intravenous an-
tibiotics for suspected diverticulitis, but increasing abdomi-
nal pain led to his hospital presentation. Physical examina-
tion revealed a body temperature of 37.4℃ and an 8 cm-
Abstract sized painful mass in the left lower quadrant. Laboratory
tests showed a normal white cell count (4.6 × 109/L) and
Left-sided periappendiceal abscesses occur in association
an elevated C-reactive protein concentration (104 mg/L).
with two types of congenital anomaly: intestinal
Computed tomography (CT) abdominal scanning revealed
malrotation and situs inversus. It is difficult to obtain an
a solid fluid-containing tumor in the left lower quadrant
accurate preoperative diagnosis of these abscesses due
to the abnormal position of the appendix. We present
(Figure 1), suggesting an inflammatory mass with abscess
an unusual case of a left-sided periappendiceal abscess formation. We drained the abscess using percutaneous
in an adult with intestinal malrotation, the diagnosis of drainage (PCD) and administered intravenous antibiotics
which was a challenge. while trying to determine the exact cause of the abscess.
One week later, the patient had a soft abdomen with no
© 2006 The WJG Press. All rights reserved. specific complaint.
To identify the cause of the abscess, we performed a
Key words: Left-sided periappendiceal abscess; Intestinal contrast enema with gastrograffin. This procedure revealed
malrotation; Diagnosis that a fistulous tract of the colon did not exist, and the
entire colon was seen in the left half of the abdomen with
Lee MR, Kim JH, Hwang Y, Kim YK. A left-sided periappendi- the cecum in the left lower quadrant (Figure 2). Contrast
ceal abscess in an adult with intestinal malrotation. World J filling of the terminal ileum was apparent. An irregular
Gastroenterol 2006; 12(33): 5399-5400 contour of the cecum was also observed, with no contrast
filling of the appendix. Figure 2 also shows a pig-tail cath-
http://www.wjgnet.com/1007-9327/12/5399.asp eter located in the area corresponding to an abscess pock-
et. With this information, the abdominal CT was again re-
viewed. Further review indicated a periappendiceal abscess
with intestinal malrotation due to the anatomic location of
the right-sided small bowel, left-sided large bowel, the ab-
INTRODUCTION normal position of the superior mesenteric vessels, and an
Intestinal malrotation is a congenital anomaly referring to inflammatory mass in the ileocecal area.
either nonrotation or incomplete rotation of the primitive Surgery was performed through a lower midline inci-
intestinal loop around the axis of the superior mesenteric sion after obtaining informed consent. Surgical findings
artery during fetal development. While most cases of in- confirmed the severe inflammatory changes of the appen-
testinal malrotation present with bilious vomiting in the dix and ileocecal region located in the left lower quadrant
first month of life[1], rare cases present in adulthood[2]. It (Figure 3). An ileocecectomy was performed. Pathology
is important that physicians be aware of the possibility of testing indicated gangrenous appendicitis with severe peri-

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 5400 ISSN 1007-9327 CN 14-1219/ R World J Gastroenterol September 7, 2006 Volume 12 Number 33

Figure 1 CT abdominal scan showing in one of three ways[3]. Some patients present with acute
the presence of a solid fluid-containing obstructive symptoms and signs of impending abdominal
tumor in the left lower quadrant (arrow).
→ catastrophe. Others present with chronic abdominal com-
L plaints that include both pain and intermittent obstruction.
Lastly, some present with atypical symptoms common to
abdominal diseases unrelated to intestinal malrotation,
such as in the present report.
The increasing use of abdominal CT as the first imag-
50 mm
ing modality in patients with various abdominal complaints
means that the importance of identifying malrotation by
CT cannot be overemphasized. Malrotation can be diag-
Figure 2 Radiograph using water-
nosed on CT by the anatomic location of a right-sided
soluble contrast media showing the
entire colon present in the left half small bowel, a left-sided colon, an abnormal relationship
of the abdomen, with the cecum in of the superior mesenteric vessels, and aplasia of the un-
the left lower quadrant. Contrast cinate process of the pancreas[4]. In the present case, such
filling of the terminal ileum is shown CT findings indicating malrotation were not immediately
▲

(arrow). Irregular contour of the

recognized due to the low frequency of this disease in the
→ cecum (arrowhead) is shown with no
contrast filling of the appendix. A pig- adult population. Malrotation was recognized only after
tail catheter is located at the area a contrast enema showed that the entire colon was in the
corresponding to the abscess pocket. left half of the abdomen, with the cecum in the left lower
quadrant. Furthermore, left-sided periappendiceal abscess
was not suspected initially because there were no clinical
R characteristics suggesting appendicitis such as preceding
vague central pain and there were only a few cases report-
ed in the literature[5].
Figure 3 Intraoperative We debated as to whether correction of the malrota-
photography showing
tion was indicated in this case. Dietz et al[2] advocated that
severe appendix infla-
mmation (arrow) and the correction of the malrotation is probably not indicated un-
ileocecal region located in less there is evidence of intestinal obstruction. In contrast,
→ the left lower quadrant. Cathcart et al[6] argued that surgical correction is warranted
due to the risk of midgut volvulus.
In conclusion, all physicians with exclusively adult pa-
tients should be familiar with intestinal malrotation in or-
der to make a timely and correct diagnosis that will lead to
prompt and appropriate treatment.

cecal inflammation. The patient recovered uneventfully REFERENCES

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Intestinal malrotation is a congenital anomaly referring to important cause of bowel obstruction in adults. Dis Colon
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S- Editor Pan BR L- Editor Zhu LH E- Editor Bai SH

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