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Table of Contents   
CASE REPORT  
Year : 2017  |  Volume : 10  |  Issue : 3  |  Page : 731-733
Primary torsion of vermiform appendix: A case report and review of literature


Department of Surgical Gastroenterology, Ronak Endo-Laparoscopy and General Surgical Hospital, Patan, Gujarat, India

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Date of Web Publication21-Aug-2017
 

   Abstract 


Appendicitis is the most common abdominal emergency with more than 250,000 appendectomy operations performed annually in the United States alone. Although appendicitis is the most common intra-abdominal surgical pathology, torsion of the appendix has only rarely been described and is an uncommon cause of an acute abdomen. The clinical picture is the same as that for acute appendicitis, and it is difficult to distinguish between them preoperatively. A case of primary torsion of the vermiform appendix is reported here along with pertinent literature review.

Keywords: Appendectomy, appendicitis, primary torsion

How to cite this article:
Yagnik VD. Primary torsion of vermiform appendix: A case report and review of literature. Ann Trop Med Public Health 2017;10:731-3

How to cite this URL:
Yagnik VD. Primary torsion of vermiform appendix: A case report and review of literature. Ann Trop Med Public Health [serial online] 2017 [cited 2019 May 23];10:731-3. Available from: http://www.atmph.org/text.asp?2017/10/3/731/213149



   Introduction Top


Torsion of the vermiform appendix is a rare phenomenon that clinically resembles acute appendicitis. The condition is difficult to distinguish preoperatively from acute appendicitis and it is invariably diagnosed on table. Torsion of the vermiform appendix was first described by Payne in 1918.[1] About sixty cases of torsion of vermiform appendix have been described in literature to date. Torsion of the appendix could either be primary or secondary. Primary torsion is rare and found to be associated with long appendix. In addition to long appendix, a fan-shaped mesoappendix with a narrow base and absence of azygotic fold, which normally attaches laterally to the appendix, are predisposing conditions for primary torsion. Secondary torsion is caused by an appendiceal abnormality, such as luminal obstruction (fecalith), inflammation, cystadenoma, lipoma, mucocele, or malformation. Although appendicitis is the most common intra-abdominal surgical pathology, torsion of the appendix has only rarely been described and is an uncommon cause of an acute abdomen. Here, I report a case of primary torsion of the vermiform appendix with comprehensive review of literature.


   Case Report Top


A 30-year-old male came to emergency room with a 2-day history of severe pain in the right lower quadrant associated with nausea, vomiting, and fever. Medical and surgical history was not significant. On physical examination, temperature was found to be 101° F, pulse 116/min, respiratory rate 20/min, and blood pressure 110/80 mmHg. Tenderness and rigidity were present in the right lower quadrant. Bowel sounds were sluggish. Per rectal examination was normal. Laboratory findings were almost normal, except for the neutrophilia with left shift. Hemoglobin was 13.3 g/dL, hematocrit 38%, platelets 225,000/cmm, and white blood cell count 18,000/mm 3. Serum analysis revealed: random blood sugar 102 mg/dL, aspartate aminotransferase 42 U/L, alanine aminotransferase 18 U/L, and creatinine 1.0 mg/dL. Urine analysis was negative for urinary tract infection and crystals. Laboratory examination showed neutrophilia with left shift. Ultrasonography revealed localized collection with noncompressible tubular structure of 11 mm diameter suggesting acute perforated appendicitis. Laparotomy was done on suspected diagnosis of acute perforated appendicitis. During laparotomy, the greater omentum was directed toward the right iliac fossa and was adherent to the appendix and cecum. Appendix was located in the retrocecal position and the base of the mesoappendix was narrow. Appendix was 9 cm in length, 1.1 cm in diameter, and showed gangrenous changes. Clockwise 280° torsion of vermiform appendix with narrow mesoappendix was revealed [Figure 1]. Appendix was filled with pus and mucus. Histopathological examination of the specimen revealed gangrenous changes and acute inflammatory infiltrate, with some area of hemorrhage in the wall. Appendicular lumen did not reveal any secondary causes such as fecalith and mucocele. Postoperative course was unremarkable, and the patient was discharged on the eighth postoperative day in good general condition.
Figure 1: Gangrenous appendix distal to torsion

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   Discussion Top


Torsion of the vermiform appendix was first described by Payne in 1918.[1] Collins studied 50,000 appendectomy specimens and did not find a single case of torsion.[2] Chang found incidence of 2 in 3003 appendectomy cases while Lee found incidence of three in 1869 appendectomy cases.[2] In 1920, Beevors reported in lancet a case of torsion of vermiform appendix.[3] In 1936, 1939, and 1949, three more cases of torsion of vermiform appendix were reported. In 1936,[4] the case was reported to be associated with pregnancy, while in 1939,[5] the case was reported to be associated with mucocele; in 1949,[6] the case was reported to be associated with Schistosoma haematobium. About sixty cases of torsion of vermiform appendix have been described in literature to date. Torsion of the appendix could either be primary or secondary. Primary torsion is rare and found to be associated with long appendix. In addition to long appendix, a fan-shaped mesoappendix with narrow base and absence of azygotic fold, which normally attaches laterally to the appendix, are predisposing conditions for primary torsion. In primary torsion, appendix shows ischemic or necrotic changes and dilatation of lumen distal to torsion without primary pathology.[7] Secondary torsion cases are attributed to luminal obstruction (fecalith), inflammation, cystadenoma,[7] lipoma, mucocele, or malformation.[7] Payne [1] described fecalith as a lead point around which irregular peristaltic movement of the appendix pivoted. Payne's concept of torsion occurring as a primary event has been supported by McFadden [8] and a few other authors. Degrees of rotation may vary from 280 to 1080 with a mean of 580. The site of torsion is variable; it can either be at the base or at 1 cm or more away from the base.[2],[9] A few authors have reported that direction of the torsion is usually anticlockwise.[10] Cecal malposition is not rare: 6% of the population is reported to have undescended cecum. Montes-Tapia et al.[11] reported appendicular torsion with undescended cecum. Dimitriadis et al. have also reported a case of torsion in undescended cecum.[12] It is controversial still whether inflammation causes torsion or it is vice versa. Kilincaslan et al. have reported torsion of vermiform appendix presented as mass in the right iliac fossa.[13] One of the latest reports of torsion is that by Seager et al. in a patient with known case of colitis.[14] Another case of torsion of vermiform appendix has been reported in 2016 from D. Y. Patil Medical College, Pimpri, Pune, which appeared in the Nigerian Journal of Surgery.[15] A few specimens did not reveal inflammatory response, which strongly supports the concept of primary torsion. Very rarely, factors, primary as well as secondary, may be the cause in a single case. Trinca [16] proposes that as a result of the distension of the cecum associated with normal or irregular peristaltic movements, the appendix is twisted on its mesentery or kinked; if in a fixed position, it is compressed by a distended cecum against the unyielding parietes with production of temporary or prolonged ischemia. Clinical presentation is indistinguishable from that of acute appendicitis. It is more common in children as compared to adults, with males having more predispositions to torsion. Torsion of appendix may occur at any age; the youngest reported case in the literature is that of a 50-day-old child [17] who presented with intussusceptions, while the oldest case is that of a 79-year-old adult, average age being 23 years. The appearance of the appendix may vary from being minimally inflamed to that with severely gangrenous changes. The cases of torsion have also been reported in pregnant patient. Hamada et al.[18] described sonographic evidence of appearance of torsion per se; sonography showed a target-like appearance at the base of the appendix, which is known as the whirlpool sign. Uroz-Tristan et al.[19] reviewed the literature and discussed the value of ultrasound images and possible mechanism involved. Findings on computed tomography (CT) scan include: diameter of >6 mm, failure of appendix to fill with oral contrast up to its tip, fecalith, contrast enhancement of wall, and sometimes lumen of the cecum pointing toward the obstructed opening (arrowhead sign). Hebert and Pickhardt.[20] reported acute torsion of an appendiceal mucocele, diagnosed preoperatively through multidetector CT (MDCT). Findings of MDCT included: dilated appendicular lumen and identification of oral contrast material in the cecum but not in the abnormal appendix. At the appendicular base, abrupt luminal tapering was noted with a whorled appearance of the supplying mesenteric fat and vessels. Torsion of the vermiform appendix leading to a small bowel obstruction has been reported by Inoue et al.[21]

Histopathological findings are the same as those for acute appendicitis (complicated or uncomplicated). Diagnosis of appendicitis requires neutrophilic infiltration of the muscularis propria. Appendectomy specimen may also show serosal fibrinopurulent reaction, focal abscess, or large area of hemorrhagic ulcerations and gangrenous necrosis. Appendectomy is the treatment of choice for torsion of vermiform appendix. The appendix may have intrinsic predisposition to torsion. After untwisting, appendectomy should be performed. Ligation of the stump should be performed as close to the base as possible to avoid future torsion in the stump.


   Conclusion Top


Torsion of the vermiform appendix is a rare phenomenon. It can be primary or secondary. The clinical picture is the same as that for acute appendicitis and it is difficult to distinguish between them preoperatively. The diagnosis can be made only intraoperatively. Although appendicitis is the most common intra-abdominal surgical pathology, torsion of the appendix has only rarely been described and is an uncommon cause of an acute abdomen. When a patient presents with diagnosis indicating acute appendicitis, torsion should be considered in the differential diagnosis.

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   References Top

1.
Payne JE. A case of torsion of the appendix. Br J Surg 1918;6:327.  Back to cited text no. 1
    
2.
Merrett ND, Lubowski DZ, King DW. Torsion of the vermiform appendix: A case report and review of literature. Aust N Z J Surg 1992;62:981-3.  Back to cited text no. 2
    
3.
Beevors EC. Torsion of the appendix. Lancet 1920;195:597-8.  Back to cited text no. 3
    
4.
Flatley G. Torsion of the vermiform appendix associated with pregnancy. Lancet 1936;227:1357.  Back to cited text no. 4
    
5.
Heatley TF. Hemorrhagicmucocele of the appendix. J Am Med Assoc 1939;112:1935.  Back to cited text no. 5
    
6.
Hughes M. A case of bilharzia of the appendix, with strangulation of ileum. Br J Surg 1949;36:428.  Back to cited text no. 6
    
7.
Kitagawa M, Kotani T, Yamano T, Tsurudome H, Hatakeyama T, Kuriu Y, et al. Secondary torsion of vermiform appendix with mucinous cystadenoma. Case Rep Gastroenterol 2007;1:32-7.  Back to cited text no. 7
    
8.
McFadden GD. Torsion of the meso-appendix associated with gangrene of the appendix. Br Med J 1920;2:1223.  Back to cited text no. 8
    
9.
Petersen KR, Brooks L, Pedersen H. Torsio appendicis vermiformis. Report of an unusual case. Acta Chir Scand 1982;148:383-4.  Back to cited text no. 9
    
10.
Gopal K, Kumar S, Grewal H. Torsion of the vermiform appendix. J Pediatr Surg 2005;40:446-7.  Back to cited text no. 10
    
11.
Montes-Tapia F, Quiroga-Garza A, Abrego-Moya V. Primary torsion of the vermiform appendix and undescended cecum treated by video-assisted transumbilical appendectomy. J Laparoendosc Adv Surg Tech A 2009;19:839-41.  Back to cited text no. 11
    
12.
Dimitriadis PA, Makar RR, Randall JK, Ramus J. Appendiceal torsion associated with undescended caecum: A case report and review of the literature. BMJ Case Rep 2012;2012. pii: Bcr2012006932.  Back to cited text no. 12
    
13.
Kilincaslan H, Gedik AH, Bilici M, Cakir S. Rare case of an abdominal mass presenting as acute abdomen: Torsion of the vermiform appendix. Pediatr Int 2013;55:e14-6.  Back to cited text no. 13
    
14.
Seager A, Gill M, Jones LS. Right iliac fossa pain from a grossly enlarged and torted appendix in a patient with known colitis. Ann R Coll Surg Engl 2016;98:e136-7.  Back to cited text no. 14
    
15.
Dubhashi SP, Khadav B. Appendicular torsion. Niger J Surg 2016;22:41-2.  Back to cited text no. 15
[PUBMED]  [Full text]  
16.
Trinca AJ. Some observations on the pathology of appendicitis. Aust N Z J Surg 1936;5:258-67.  Back to cited text no. 16
    
17.
Yeung CK, Saing H. Primary torsion of the vermiform appendix in a 50-day-old infant. Pediatr Surg Int 1991;6:223-4.  Back to cited text no. 17
    
18.
Hamada T, Kosaka K, Shigeoka N, Hashimoto Y, Yamauchi M, Cho S, et al. Torsion of the appendix secondary to appendiceal mucocele: Gray scale and contrast-enhanced sonographic findings. J Ultrasound Med 2007;26:111-5.  Back to cited text no. 18
    
19.
Uroz-Tristan J, García-Urgelles X, Poenaru D, Avila-Suarez R, Valenciano-Fuentes B. Torsion of vermiform appendix: Value of ultrasonographic findings. Eur J Pediatr Surg 1998;8:376-7.  Back to cited text no. 19
    
20.
Hebert JJ, Pickhardt PJ. MDCT diagnosis of an appendiceal mucocele with acute torsion. AJR Am J Roentgenol 2007;189:W4-6.  Back to cited text no. 20
    
21.
Inoue S, Odaka A, Muta Y, Yanagida H, Osada H, Tamura M. Small bowel obstruction associated with torsion of the vermiform appendix: Case report. J Pediatr Surg Case Rep 2013;1:383-5.  Back to cited text no. 21
    

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Correspondence Address:
Vipul D Yagnik
77, Siddhraj Nagar, Rajmahal Road, Patan - - 384 265, Gujarat
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ATMPH.ATMPH_25_17

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