An unusual presentation of perforated appendicitis in epigastric region.
BACKGROUND
Atypical presentations of appendix have been reported including backache, left lower quadrant pain and groin pain from a strangulated femoral hernia containing the appendix. We report a case presenting an epigastric pain that was diagnosed after computed tomography as a perforated appendicitis on intestinal malrotation.


METHODS
A 27-year-old man was admitted with a three-day history of epigastric pain. Physical examination revealed tenderness and defense on palpation of epigastric region. There was a left subcostal incision with the history of diaphragmatic hernia repair when the patient was 3 days old. He had an intestinal malrotation with the cecum fixed at the epigastric region and the inflamed appendix extending beside the left lobe of liver.


CONCLUSIONS
While appendicitis is the most common abdominal disease requiring surgical intervention seen in the emergency room setting, intestinal malrotation is relatively uncommon. When patients with asymptomatic undiagnosed gastrointestinal malrotation clinically present with abdominal pain, accurate diagnosis and definitive therapy may be delayed, possibly increasing the risk of morbidity and mortality.


CONCLUSIONS
Atypical presentations of acute appendicitis should be kept in mind in patients with abdominal pain in emergency room especially in patients with previous childhood operation for diaphragmatic hernia.
Department of Surgery, Haydarpasa Numune Education and Research Hospital, Istanbul 34688, Turkey. Electronic address: hmodabasi@gmail.com.
Mehmet
M
Odabasi
Department of Surgery, Haydarpasa Numune Education and Research Hospital, Istanbul 34688, Turkey.
Cem
C
Arslan
Department of Surgery, Haydarpasa Numune Education and Research Hospital, Istanbul 34688, Turkey.
Hasan
H
Abuoglu
Department of Surgery, Haydarpasa Numune Education and Research Hospital, Istanbul 34688, Turkey.
Emre
E
Gunay
Department of Surgery, Haydarpasa Numune Education and Research Hospital, Istanbul 34688, Turkey.
Mehmet Kamil
MK
Yildiz
Department of Surgery, Haydarpasa Numune Education and Research Hospital, Istanbul 34688, Turkey.
Cengiz
C
Eris
Department of Surgery, Haydarpasa Numune Education and Research Hospital, Istanbul 34688, Turkey.
Erkan
E
Ozkan
Department of Surgery, Haydarpasa Numune Education and Research Hospital, Istanbul 34688, Turkey.
Ali
A
Aktekin
Department of Surgery, Haydarpasa Numune Education and Research Hospital, Istanbul 34688, Turkey.
M A Tolga
MA
Muftuoglu
Diaphragmatic hernia; Epigastric; Laparoscopy; Malrotation; Perforated appendicitis; Unusual presentation