Appendicular Torsion: A Case Report And A Review of The Pertinent Literature

Appendicular torsion (AT) is a rare disorder often diagnosed intra-operatively during a diagnostic laparoscopy (DL). AT is hardly detected by pre-operative radiologic investigations such as abdominal ultrasound (US). The anticlockwise torsion can completely obstruct the appendicular lumen compromising blood supply and leading to strangulation, venous infarction, and bacterial translocation. Clinical presentation is undistin-guishable from acute appendicitis and must be included in the differential diagnosis of patients with right lower quadrant abdominal pain (RLQAP). Herein we report a rare case of a 24-year-old female with a 200-degree clockwise primary rotation of the retro-cecal appendix, and we offer a review of the pertinent literature.


Introduction
Appendicular torsion (AT) is a rare condition, often diagnosed intraoperatively and clinically indistinguishable from acute appendicitis, one of the most typical causes of urgent surgery [1].AT can be primitive (or idiopathic) when related to specific anatomical features such as a lengthy appendix, a fan-shaped mesoappendix with a narrow base, or the absence of azygotic folds, which usually fix the appendix laterally [2,3].Secondary forms of AT occur when the twist is after other pathological conditions like coprolith impaction, mucocele, carcinoid tumor, mesoappendiceal lipoma, foreign bodies, or lymphadenitis [4,5].AT symptoms usually mimic the ones associated with acute appendicitis: abdominal pain in the right iliac fossa, nausea, and vomiting.Consequently, AT should be included in the differential diagnosis of patients with right lower quadrant abdominal pain (RLQAP).Some findings on pre-operative radiologic imaging could suggest the presence of a torsion -particularly the secondary forms of AT -but abdominal US is not the gold standard to detect.An abdominal CT scan is undoubtedly a more sensitive examination, but it is not always performed in the preoperative workup.For all these reasons, AT is most frequently diagnosed during a diagnostic laparoscopy (DL) [6].

Case Report
A 24-year-old woman presented to the emergency department complaining of a 3-day history of colicky pain in the right iliac fossa, anorexia, and vomiting.There was no significant record in her past medical history.A physical examination of the abdomen revealed pain localized in the right iliac fossa and distention, guarding, and rebound tenderness.Blood tests showed a total leucocyte count of 15,300/mm and a C-reactive protein level of 0.08 mg/dL.The first bedside ultrasonography did not detect any clear signs of appendichopathy.After an unremarkable gynecological consultation, a second US was executed after 24 hours, showing an amount of collection in the right iliac fossa with local lymphadenitis.An emergency appendectomy with a laparoscopic approach was performed.Intraoperatively, there was evidence of torsion of the vermiform appendix with a clockwise rotation of 200 degrees around 1 cm from the base of the appendix (Figure 1).
The appendix appeared retrocausal, long, and congested.The mesentery was short compared to the length of the appendix.Some adhesions were present between the appendix and the surrounding tissues.
We finally proceeded to remove the appendix.Histopathology confirmed the AT diagnosis: a luminal dilatation was found distally to the torsion site, and the appendicular wall had already developed necrosis.The appendix measured 9.5 cm in length.The postoperative course was uneventful, and the patient was discharged on the fourth postoperative day.1).
The population most frequently affected is male pediatric patients and young adults.The median age is 33 old.Most of the cases are primitive (60 %).The anatomic feature most favoring AT is the length of the appendix.Theoretically, the longer the appendix, the higher the risk of torsion.The most extended appendix ever reported measured 55 cm in length [8].The literature review shows 20 AT cases in which the appendix was longer than 10 cm.The twist usually occurs in the long axis of the appendix and begins at the base or at least 1 cm from that, but it could also be more distal.The degree of torsion is usually between 180 and 1080 degrees.The direction is most commonly anticlockwise.Reviewing the pertinent literature, the tumors most frequently causing secondary AT are mucous cystadenomas (5 cases) and mucoceles (10 points) (Table 1).

Conclusion
AT shows a clinical presentation similar to acute appendicitis.Preoperative diagnosis can be reached through a preoperative contrastenhanced CT scan of the abdomen.For secondary forms of AT, a tumor must be excluded.AT must be included in the differential diagnosis of pain localized in the right iliac fossa.
Written informed consent was obtained from the patient to publish this Case Report and any accompanying images.A copy of the written permission is available for review by the Editor-in-Chief of this journal.

Figure 1 :
Figure 1: Evidence of torsion of the vermiform appendix with a clockwise rotation of 200 degrees around 1 cm from the base of the appendix

Table 1 :
Appendicular Torsion : review of the literature

Authors Year Age Sex Degree/direc- tion of rota- tion Lenght of ap- pendix, cm Etiology or complication
On the other hand, the US represents the right choice for simple acute appendychopathy.In our case report, the torsion was idiopathic with no evidence of local lesion causing rotation.Treatment of AT is dependent on the underlying cause.An appendectomy is sufficient in case of a primary torsion without any abnormal lesions.
https://doi.org/10.38207/JMCRCS/2023/APR04050127Citation: Montali F, Boriani E, Stefania B, Annichiarico A, Virgilio E, et al. (2023) Appendicular Torsion: A Case Report And A Review of The Pertinent Literature.J Med Case Rep Case Series 4(05): https://doi.org/10.38207/JMCRCS/2023/APR04050127However, using conservative therapy with antibiotics for AT can cause necrosis of the appendix, leading to perforation of the appendix and peritonitis.The optimal treatment should consist of prompt laparoscopic detorsion and appendectomy to avoid complications secondary to appendiceal perforation and potential intraperitoneal spillage of appendiceal or mass contents.Despite being a surgical rarity, AT should always be considered in the differential diagnosis of patients with right lower quadrant abdominal pain (RLQAP).