Intestinal malrotation and acute left side appendicitis: an indication for laparoscopic exploration.

To cite: Sedano-Vizcaíno C, Goulart A, Moreno-Sanz C, et al. BMJ Case Rep Published online: [please include Day Month Year] doi:10.1136/bcr-2015210412 DESCRIPTION A 67-year-old woman with a medical history of arterial hypertension was admitted to the emergency department with 1-day evolution of abdominal pain. The patient presented continuous pain at the lower abdomen associated with nausea and vomiting. On physical examination, she had pain without tenderness at the lower abdomen. Laboratory tests showed an elevated white cell count (15 900/μL with left shift) and a C reactive protein level of 17.2 mg/dL (normal range <0.5 mg/dL). A chest and abdominal X-ray did not show any alterations. A CT scan with intravenous and oral contrast was performed, and showed findings of complete intestinal malrotation with the entire colon shifted to the left and small bowel moved to the right (figure 1A). The caecum was positioned at the lower pelvis, and the appendix presented dilation and thickening with small bubbles of extraluminal air, and had a small quantity of liquid at the Douglas pouch, suggestive of acute perforated appendicitis (figure 1B, C). The patient underwent exploratory laparoscopy. The complete intestinal malrotation was confirmed, and a gangrenous and perforated appendix with small quantity of purulent fluid was observed at the left of the pelvis (figure 2A). Laparoscopic appendectomy was performed with the base of the appendix double ligated with Endoloop Ligature (polyglactin 910, Ethicon) on healthy tissue (figure 2B). The appendix was removed with a laparoscopic bag and toilet peritoneal lavage performed. The postoperative period was complicated by an 8 mm×17 mm abdominal abscess treated with percutaneous drainage and antibiotics. True left-sided acute appendicitis develops in association with two types of congenital anomalies: situs inversus and intestinal malrotation. Intestinal malrotation is a congenital positional anomaly of the intestine caused by non-rotation or incomplete rotation of the primitive loop around the axis of the superior mesenteric artery. Malrotation occurs in one of every 500 births; most cases of malrotation are detected by 1 year of age and the true incidence in adults is unknown. A review from 2010 encountered 95 published cases of left-sided appendicitis, with only 23 associated with intestinal malrotation. Laparoscopic appendectomies for acute appendicitis associated