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Case Study
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Case Study
Marilyn, a patient who was a 27-year-old female, who presented to the emergency department complaining of sudden periumbilical pain that radiates to the RLQ (right lower quadrant) and suffered with sudden onset cramping in the mid-abdomen that worsened to sharp, constant, non-radiating pain with intermittent episodes of more intense stabbing pain in the RLQ.
Valentino’s syndrome is an uncommon cause of right lower quadrant pain and symptoms mimicking acute appendicitis (Cherry, Patel, & Ronaghan, 2019). One of the most common causes of right lower quadrant (RLQ) abdominal pain is acute appendicitis. The most frequent symptoms observed are periumbilical pain that radiates to the right lower quadrant, anorexia, nausea, and vomiting. Other conditions that mimic acute appendicitis at presentation include ovarian torsion, ruptured ectopic pregnancy, pseudomembranous colitis, and perforated cholecystitis (Cherry, Patel, & Ronaghan, 2019). Here, we present a unique case of Valentino’s syndrome, wherein a perforated duodenal ulcer manifested the same constellation of symptoms as acute appendicitis. Valentino’s syndrome, named for the popular silent film actor Rudolph Valentino, was first described after he developed the signs and symptoms of appendicitis and underwent an appendectomy that failed to relieve his symptoms. He later developed overt peritonitis and developed multi-organ failure, to which he later succumbed. During his autopsy, it was discovered that he had been suffering from a perforated peptic ulcer.
After perforation of the duodenal ulcer, inflammatory fluid and alimentary tract contents seeped into the abdomen and trickled down the right colic gutter. As the purulent fluid remained in the abdomen, it caused peritonitis and referred pain from the same general area as the appendix, leading to the development of signs and symptoms mimicking acute appendicitis. Noted that the ulcer was not visualized endoscopically, it requires vigilant gross examination of the duodenum led to identification of a pinhole perforation and diagnosis of Valentino’s syndrome. Thus, careful attention to alternative causes of acute right lower quadrant pain is critical in the workup of acute abdomen, both preoperatively and intraoperatively (Afenigus, Bayieh, & Kassahun, 2022).
The most common intraoperative findings were an inflamed/phlegmonous appendix followed by perforated appendix. The other intra operative findings were appendiceal abscess, gangrenous appendix, fecalith, appendicular mass, normal appendix and other findings such as inflammatory peritoneal fluid collection, ectopic kidney, and cecal mass and edematous pancreas (Afenigus, Bayieh, & Kassahun, 2022).
In the study of Kassahun, Afenigus, Bayieh (2020) mentioned that the diagnosis of acute appendicitis is generally made from clinical examination (history, physical examination), laboratory investigation and/or imaging devices (ultrasound, CT scan and MRI). However, there is limited access to high quality advanced imaging modalities (CT scan, MRI) in most settings in Ethiopia. Besides this, most surgeons in Ethiopia remove the appendix through an open incision in the right lower abdominal wall rather than laparoscopically in most settings. This further prolongs the patient’s postoperative pain, hospital stay, and return to bowel function and normal activity. Therefore, assessing the treatment outcome and the factors associated with acute appendicitis is crucial.
References
Afenigus, A. D., Bayieh, A. M., & Kassahun, B. (2022). Treatment outcomes of acute appendicitis and associated factors among admitted patients with a diagnosis of acute abdomen in Debre Markos referral hospital, Amhara region, North West Ethiopia. Journal of Perioperative Practice, 32(5), 123-130.
Cherry, B. H., Patel, D., & Ronaghan, J. E. (2019). A Case of Valentino’s Syndrome Presenting as Possible Appendicitis. International Surgery, 104(11-12), 540-541.
Kassahun, B., Afenigus, A.D., Bayieh, A.M. (2020). Treatment outcomes of acute appendicitis and associated factors among admitted patients with a diagnosis of acute abdomen in Debre Markos Referral Hospital, Amhara Region, North West Ethiopia. Journal of Perioperative Practice, 0(0) 1–8.
2017/5093
