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Torsion of the Vermiform Appendix-Report of 2 cases

Réka Somogyi¹, Balázs Kutasy², István Csízy², E. Cholnoky¹,G. Mohay¹, Rita Hajdu¹, András Pintér¹
¹Department of Pediatrics, University of Pécs, Hungary
²Department of Pediatrics, University of Debrecen, Hungary

 

 

Correspondence

Prof Andrew B. Pinter
h-7623 József A. str. 7, Pécs, Hungary
tel: + 36 20 956 4169
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Abstract

The authors report the torsion of the vermiform appendix in two 5-year old boys. Its clinical signs and symptoms (vomiting, increasing tenderness and later muscular rigidity in the right lower abdomen) and investigations (ultrasonography proved appendicular involvement) were similar to that of acute appendicitis. The vermiform appendices were torsioned 360o and 720o on their bases with their mesentery rotated in counter-clockwise direction, respectively. The appendices were gangrenous in appearance but without evidence of inflammation.

Key words: appendix, appendicular torsion, acute abdomen

  

Introduction

The torsion of the vermiform appendix is a rare condition with about 25 case reports in the English-language literature since its first description in 1918 [1]. This condition is seen more frequently in children than in adults and the male:female ratio is 4.5:1. The signs and symptoms are similar to appendicitis, therefore preoperative diagnoses is rare. When it remains untreated it can lead to necrosis of the appendix and peritonitis. We present two cases discovered at laparotomy performed for acute appendicitis.

Case reports

Patient 1

A five-year-old boy presented with 12-hour history of periumbilical and later right-sided colicky abdominal pain and vomiting. Temperature was 37.5°C. The lab results showed mild infective signs (WBC: 14000/mm3, CRP: 26.2 mg/l, ESR: 8 mm/1 hour). An abdominal ultrasound showed a 4 cm long appendix with thickened wall (15-18 mm), fluid in the Douglas cavity (Fig.1.a, 1.b). The abdominal pain intensified, muscular rigidity was found and therefore a laparotomy was performed. At operation 14 cm long appendix was found torted 720 degrees, at 1 cm from its base in a counter-clockwise direction (Fig.1.c.). The appendix was deep purple in colour, swollen with macroscopic signs of congestion and hemorrhagic infarction. There was no evidence of perforation, associated adhesions or suppuration. A routine appendectomy was performed. Cut surface of the appendix: empty lumen, mucous membrane was necrotic but no sign of inflammation (Fig.1.d.). Bacteria culture from the abdominal fluid was negative. Histological examination of the appendix showed hemorrhagic infarction and oedema with dilated veins. Postoperative recovery was uneventful.

vermilon1

Figure 1. Patient 1 (a) abdominal sonography: 4 cm long appendix with thickened wall (15-18 mm) – transversal view; (b) longitudinal view ; (c) appendix is torsioned 720 degrees in counter - clockwise direction ; (d) cut-surface of the appendix: empty lumen, necrotic mucous membrane without signs of inflammation

Patient 2

A five-year-old boy presented with a 48-hour history. The symptoms were similar to the first case, periumbilical abdominal pain, vomiting. Physical examination revealed periumbilical and later right lower quadrant tenderness. The temperature was 38°C. Lab results showed infective signs (WBC: 21000/mm3, CRP: 79 mg/l). Abdominal ultrasound documented periappendicular fluid, but no other pathological signs. During laparotomy a 320 degrees, counter-clockwise rotated appendix was found, without inflammation. The wall of the appendix was haemorrhagic and thickened without inflammation indicating a primary ischemia. An appendectomy was carried out. From the abdominal fluid Escherichia coli and Streptococcus were cultured. Pathological examination showed a gangrenous appendix. Recovery was uneventful.

Discussion

The torsion occurs as a result of twisting of the appendix along its longitudinal axis. The location of torsion is usually, at least 1 centimetre from the base of the appendix and is less frequent at the base [2]. The degree of torsion is usually between 180-1080°. The direction of rotation is variable, but counter-clockwise is more frequent. This condition leads to obstruction of the lumen, compromising the lymphatic drainage and venous return and cutting off the arterial supply, with resulting strangulation, haemorrhagic infarct and secondary inflammatory response, presenting clinically as an acute abdomen [2].

Primary torsion of the appendix occurs without a known predisposing factor. A fan-shaped mesoappendix with a narrow base and the abnormal position of the coecum might be a cause [3]. The longer appendix (>7cm) can predispose to torsion. However, secondary torsion has been reported to occur in association with mucocele, carcinoid tumor, lipoma [4], and infestation with parasites, such as Schistosoma haemotobium. In our both cases the torsion was primary, there were no predisposing factors, and the directions of the torsion were in both cases counter-clockwise. In our cases, abdominal ultrasound did not diagnose the torsion of the appendix. In the literature there is no data about the characteristic US imagine of appendiceal torsion, only Uroz-Tristan and co-workers reported a case where US examination rendered torsion beside the inflammation of the appendix [5]. It was noteworthy, that blood chemistry (sedimentation rate, white blood cell count, C-reactive protein) mainly in the first patient documented moderate inflammation which was in contrast with the advanced clinical picture of acute abdomen. In the area of minimal invasive surgery, laparoscopy can prove the torsion and the torsioned appendix can be removed laparoscopically [3].

Conclusion

There is a consensus that the appendicular torsion can not be distinguished from acute appendicitis preoperatively. However, the laboratory tests (lack of characteristic signs of inflammation), the advancements in US imaging and the rapidly growing use of diagnostic (preoperative) laparoscopy might modify this general view. Therefore, general and paediatric surgeons should be familiar with the refinements of diagnostic possibilities on the torsion of the vermiform appendicitis.

 

 

REFERENCES 

  1. Payne Je. a case of torsion of the appendix. 1918; br. J. Surg. 6: 327.
  2. Tzilinis a, vahedi mh, wittenborn wS. appendiceal torsion in an adult: case report and review of the literature. Curr. Surg. 2002; 59: 410-411
  3. Dewan Pa, woodward a. torsion of the vermiform appendix. J. Pediatr. Surg. 1986; 21: 379.
  4. Legg nGm. torsion complicating mucocele of the appendix J. r. Coll. Surg. edinb. 1973; 18: 236.
  5. Uroz-tristan J, Garcia-urguelles J, Poenare d, avila-Suarez r, velanciano- fuentes, b. torsion of vermiform appendix: value of ultrasonographic finding. eur. J. Pediatr. Surg. 1988; 8:376-7.