First Report of Preoperative Imaging Diagnosis of a Surgically Confirmed Case of Valentino's Syndrome

Abstract

Perforation of a duodenal ulcer (DU) into the retroperitoneal space presenting with clinical features of acute appendicitis is known as Valentino's syndrome. Post duodenal perforation, the gastric and duodenal fluids tend to settle in the right paracolic gutter causing peritonitis and clinically mimicking acute appendicitis. Only three cases of Valentino's syndrome have been reported till date in the published literature and there is only one previous report of its preoperative imaging diagnosis. To our knowledge, this is the first reported case of preoperative imaging diagnosis in a surgically confirmed case of Valentino's syndrome. In most cases, patients with undiagnosed Valentino's syndrome are operated for acute appendicitis, and on finding a normal appendix, search is made for the cause of peritonitis, which then leads to retroperitoneal perforation of duodenum. The diagnosis of Valentino's syndrome by computed tomography (CT) imaging is easy and can help in avoiding the surgery or directing the surgeon directly to the repair of the duodenal perforation. It is, therefore, essential for emergency physicians, surgeons, and radiologists to know about this entity and consider it in the differential diagnosis.

A rare case of Valentino’s syndrome

“…In many cases, the perforation is found intra-operatively. 7 Diagnosis can be confirmed with radiological evidences. Ultrasonogram may reveal free fluid collection in right iliac fossa with features of appendicitis.…”

Valentino’s Syndrome: A Life-Threatening Mimic of Acute Appendicitis

“… 2 This case highlights Valentino’s syndrome, in which the patient presents with pain in the right lower quadrant (RLQ) of the abdomen due to perforation of a duodenal ulcer through the retroperitoneum. 3 , 4 , 5 , 6 To our knowledge, this is only the second reported case of Valentino’s syndrome in the emergency medicine literature.…”

“…Localized pain to the RLQ can mimic acute appendicitis so closely that surgical exploration without imaging has lead to the diagnosis being made intra-operatively. 3 As time passes, this can progress to focal tenderness, as in this case, or to generalized peritonitis. Initial imaging other than CT may demonstrate free fluid around a normal appendix on ultrasound and free air around the kidney, or “veiled kidney sign” on abdominal radiographs.…”

“…Valentino’s syndrome occurs when gastric or duodenal fluid collects in the right paracolic gutter causing focal peritonitis and RLQ pain. 3 , 4 , 5 , 6 The syndrome is named after the 1920s silent film star Rudolph Valentino. In 1926, Valentino collapsed in a New York City hotel and underwent surgery for presumed appendicitis at New York Polytechnic Hospital.…”

“…These contents will collect in dependent portions of the peritoneum, which is often the RLQ. 3 If the patient seeks medical attention early in the course of the disease, he or she may have poorly localized pain. Localized pain to the RLQ can mimic acute appendicitis so closely that surgical exploration without imaging has lead to the diagnosis being made intra-operatively.…”