Appendiceal torsion: a rare case of acute appendicitis

Abstract

We describe a case of a previously well 56 year-old male who presented to a hospital with a 24-hour history of acute abdominal pain. The pain progressed over six hours from the periumbilical area to the right iliac fossa, associated with nausea and vomiting, without fever or changes in bowel habits. Clinical examination demonstrated exquisite tenderness over McBurney's Point, with guarding and focal peritonism. Vital signs were stable and inflammatory markers were not raised. A computerized tomography (CT) scan of the abdomen was ordered to corroborate clinical findings which demonstrated fat stranding around the vermiform appendix and atypical gaseous distension of the appendiceal lumen.Laparoscopic appendicectomy was performed, macroscopic findings were a gangrenous, non-perforated appendix, with torsion at the base of appendix and mesoappendix between 270 and 360 (Fig. 1). There were dense adhesions between the terminal ileum, caecum, and abdominal wall, encasing the appendix and contributing to the torsion (Figs. 2 and 3). The appendix was excised in the usual manner, and the congenital adhesions lysed. The patient recovered well postoperatively and was discharged on postoperative day two. Histopathological examination of the appendix demonstrated acute gangrenous appendicitis, characterised by necrosis of the distal half of the appendix wall, mucosal ulceration, haemorrhage, serosal fibrin deposition and full-thickness neutrophilic infiltration of the appendix wall, without evidence of malignancy or perforation.