International Surgery Journal

Chávez AMG et al. Int Surg J. 2017 May;4(5):1813-1817

http://www.ijsurgery.com pISSN 2349-3305 | eISSN 2349-2902

DOI: http://dx.doi.org/10.18203/2349-2902.isj20171647
Case Report

Valentino’s syndrome: the simulation of an appendicitis

Alberto Manuel González Chávez*, Alain Arturo García Vázquez,
José Manuel Gómez López, Nicolás Leyva Pavón, José Luis Lemus Gómez,
Diego Abelardo Álvarez Hernández, Mauricio Valdez Durón

Department of Gastrointestinal Surgery, UNAM Hospital Español de México, CDMX, México

Received: 03 March 2017

Accepted: 31 March 2017

*Correspondence:
Dr. Alberto Manuel González Chávez,
E-mail: [email protected]

Copyright: © the author(s), publisher and licensee Medip Academy. This is an open-access article distributed under
the terms of the Creative Commons Attribution Non-Commercial License, which permits unrestricted non-commercial
use, distribution, and reproduction in any medium, provided the original work is properly cited.

ABSTRACT

Acute abdominal pain is still the domain of the surgeon. Among the many differential diagnosis that should be
considered, acute appendicitis must be one of the main options for the clinician. Even though we have excellent
diagnostic tools nowadays, accomplishing an accurate diagnosis is not that easy. We all know that is better to perform
surgery on a normal appendix than not operating an appendix that will result in complications; we also know that the
diagnostic challenge will be higher in a female patient. But, what if right lower quadrant pain is produced by a
pathology that doesn’t involve that anatomical region? We present two cases that clearly explain this situation.

Keywords: Abdominal pain, Acute abdomen, Appendicitis, Peptic ulcer, Valentino’s syndrome

INTRODUCTION Pathologies that can simulate acute appendicitis

Acute appendicitis is one of the main causes of acute • Crohn’s disease

abdomen, and the most common cause of urgent • Tubo-ovarian abscess
abdominal surgery in the world.1 It’s a pathology with a • Acute ileocecal enterocolitis (typhlitis)
vast number of differential diagnosis, and even though • Sigmoid diverticulitis
we have diagnostic tests with great sensitivity and • Cecum tumors
specificity, it continues to be a challenge for the surgeon. • Colorectal cancer
Several studies report a diagnostic error between 5 and
• Appendix tumors
15% when approaching a patient with abdominal pain
• Perforated acute cholecystitis
that suggests appendicitis.2
• Gastric or duodenal perforated ulcer
In fact, at least 10% of all appendectomies made by a • Pseudomembranous colitis and CMV in AIDS
single surgeon should be reported with no pathological positive patients
finding, otherwise he could be missing true cases of • Ovarian torsion
appendicitis or diagnosing them too late.2 • Necrotic/hemorrhagic leiomyomas
• Endometriosis
Diagnostic errors occur more frequently in female • Ovarian vein thrombosis
patients because of anatomical reasons.1 Some of the • Infectious ileocecitis
pathologies that commonly imitate acute appendicitis are • Epiploic appendagitis or epiploic appendix torsion
listed below: • Mesenteric adenitis

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• Right colonic diverticulitis Being not conclusive for a definite diagnosis, a CT scan
was performed, which reported free air and liquid in the
It is called Valentino’s syndrome to the signs and abdominal cavity with predominance in the right flank
symptoms that mimic an acute appendicitis, but are in and iliac fossa with no contrast material leakage and not
fact produced by a perforated gastric or duodenal ulcer.4 finding a specific perforation site or the appendix (Figure
Once the visceral wall rupture occurs, gastric or intestinal 2).
fluids migrate to the right iliac fossa through the
paracolic gutters, producing a periappendicits. It is
known by this name in honour to the Italian actor
Rudolph Valentino, who died in 1926 due to peritonitis
produced by a gastric ulcer perforation, that in the
beginning simulated an acute appendicitis.5 In this article,
we present two clinical cases in which the suspicion of
acute appendicitis was ruled out during the surgical
event.

CASE REPORT

Case 1 Figure 2: Gastric fluid pathway through the right

paracolic gutter, which induced peritoneal irritation
A 26-year-old male patient, with no family history of in the right iliac fossa.
importance, with a smoking index of 13 points. Drug user
(cocaine and MDMA) with three months of abstinence. A diagnostic laparoscopy was performed insufflating
Eight hours prior to his arrival to the E.R. he begins with capnoperitoneum with Veress technique. Once inside the
acute colicky abdominal pain, located in the abdominal cavity, free liquid in the pouch of Douglas was
hypogastrium, with an intensity of 8 out of 10 in the pain seen with gastric characteristics and fibrin accumulation
scale, with irradiation to the right iliac fossa and flank, (Figure 3).
and was exacerbated on decubitus. Other symptoms
included hyporexia, nausea, and vomiting. Physical
examination with tachycardia and a slight increase in
body temperature.

Abdomen with involuntary muscular resistance,

hyperalgesia and pain when pressing the right iliac fossa
and flank, all of the appendicular signs present
(McBurney, Von Blumberg, Rovsing, Dunphy and
psoas). Laboratory test revealed leukocytosis of 14,500
with 13% of bands and 77% neutrophilia. Urinary test
with no abnormalities. Abdominal X-rays showed a fixed
intestinal loop in the right iliac fossa and the loss of psoas
Figure 3: Not-inflamed appendix surrounded by
shadow in the same region. As part of the surgical
gastric fluid.
approach, a abdomino pelvic ultrasound was performed,
it showed scarce free fluid in the right cul-de-sac and
An exploration of the cavity was performed finding a
mesentery infiltration (Figure 1).
gastric antrum perforation of approximately 1cm (0.4
inches) in diameter, 5cm (2 inches) next to the pylorus
(Figure 4).

Figure 1: Free fluid in the right cul-de-sac.

Figure 4: Perforated gastric ulcer.

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A primary closure with simple interrupted stitches was mediate postoperatory he presented continuous episodes
done with multifilament absorbable suture (Polysorb®) of epigastric pain with an intensity of 8/10 that remitted
and a omentum patch was placed. Patient was covered with ketorolac administration. However, he tolerated diet,
with a double antibiotic regimen of ciprofloxacin and peristalsis was present and evacuations with no
metronidazole and remained with a nasogastric tube on abnormalities where present. He was discharged with
continues suction and oral intake restriction for 5 days, cefuroxime as the antibiotic treatment. Pathology report,
gradually progressing diet. The patient outcome was obtained days later, referred periappendicitis and acute
satisfactory and mediate or late post-operatory inflammation of the mesoappendix with no acute
complications where seen. When asked about risk factors appendicitis found. Five days later after the patient
for peptic ulcer formation, the patient accepted he discharge, he returned to the E.R. with intense epigastric
consumed NSAID’s on a regular manner (400mg of pain, with an 8/10 intensity and bile vomit in 5 occasions.
ibuprofen) as recommended by his psychiatrist to Physical examination revealed fever, tachycardia and
complement abstinence syndrome treatment. signs of acute abdomen. A tangential abdominal X-ray
revealed an important pneumoperitoneum (Figure 6),
Case 2 surgical reintervention was decided.

A 76-year-old male patient, with no family history of

importance, with a smoking index of 25 points, 3 days
prior to his arrival, he begins with colicky abdominal pain
in the umbilical region, with an intensity of 6 out of 10 in
the pain scale, it then migrated to the right iliac fossa and
genitals, he also presented fatigue, anorexia, nausea and
obstipation. He seeks medical attention due to increased
pain intensity. At physical examination with stable vital
signs, protuberant abdomen due to subcutaneous fat and
meteorism, hyperalgesia and pain when pressing the right
iliac fossa. McBurney, Von Blumberg, Rosving and
Dunphy signs where positive. Laboratory findings
reported a 13,500 leukocytosis, 7% bands, and a 73.3%
neutrophilia, urinary test with no abnormalities.
Abdominal chest X-ray showed no infradiaphragmatic
air. Abdominal X rays showed dilated bowel loops in the Figure 6: Massive pneumoperitoneum due to
right lower quadrant and air-fluid levels, which suggested duodenal perforation.
ileus. As part of the diagnostic approach, an abdominal
ultrasound was performed, which revealed pericecal fluid An exploratory laparotomy was performed, finding a
and no peristalsis, the appendix was not found (Figure 5). 0.5cm (0.2 inches) perforation in the second part of the
duodenum. It was repaired using a Graham patch and
simple interrupted stitches of multifilament absorbable
suture. A cavity lavage and aspiration was done and
Saratoga drains where placed. Nasogastric tube suction
was placed, starting diet 5 days after surgery. The patient
outcome was satisfactory and was discharged 7 days after
the second surgery. Neither mediate and late
postoperatory complications where present.

DISCUSSION

When studying a patient with abdominal pain, it is

important to differentiate between acute abdominal
syndrome and acute abdominal pain. Acute abdominal
syndrome is the combination of acute abdominal pain
Figure 5: Suggestive image of acute appendicitis in the with signs of peritoneal irritation, which has many
right iliac fossa. etiologies. Acute abdominal syndrome is a surgical
urgency that represents between 5 and 10% of the
Acute appendicitis diagnosis was made and a laparoscopy consults in the E.R. and that will require immediate
appendectomy was planned. While performing surgery, management by a surgeon.3 One of the most important
purulent fluid in the right paracolic gutter and cul-de sac signs to integrate an acute abdominal syndrome is
and inflammation of the mesoappendix was found. involuntary muscular resistance. Abdominal pain, on the
Because of these findings, appendectomy was performed. contrary, has different etiologies with non-surgical
He remained 3 days hospitalized after surgery. During the causes. Even though nowadays we have many diagnostic

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tools, acute abdominal pain is still a challenge for the effects on gastrointestinal physiology are well known: 1)
surgeon. it interferes with histamine receptor activation, 2) gastric
emptying speeds up, 3) it favours duodenogastric reflux,
In a multinational study in which Mexico participated, 4) it inhibits bicarbonate pancreatic secretion and 5) it
10,682 patients with acute abdominal pain were also inhibits E2 prostaglandin production.9
evaluated, it was determined that the 4 main causes are:
1) non-specific abdominal pain, 2) acute appendicitis, 3) CONCLUSION
acute cholecystitis, 4) small bowel obstruction. Peptic
ulcer perforation ranks in the 8th position.6 When approaching a patient with acute abdomen, there
are neither established protocols nor definitive diagnostic
When having a patient with acute abdominal pain tests. With these two cases we learned that clinical data
localized in the lower right quadrant with signs of obtained by the patients history can make us think of
peritoneal irritation and systemic inflammatory response other diagnosis and not only suspect the most common
syndrome, we are obligated to discard acute appendicitis. ones. Precisely in these patients is where laparoscopic
Clinical history and physical examination are still the surgery becomes an invaluable method and superior
main tools to integrate the differential diagnosis of acute compared to others to approach a patients with abdominal
abdominal pain. In fact, determinant factors for the illness. This is why the surgeon is forced to perform a
appropriate diagnosis are: 1) pain location, 2) pain diagnostic laparoscopy during the procedure. There is a
characteristics and 3) accompanying signs.1 level A evidence recommendation to perform a
laparoscopic procedure when the possibility of acute
Surgeons have many methods to confirm diagnosis. appendicitis exists, but also when suspecting a
Abdominal CT scan with IV contrast is considered as the gastroduodenal perforation. Since 1990, Mouret showed
gold standard, it has a 94% sensitivity and 95% that a laparoscopic procedure in gastrointestinal
specificity.7 This test is not harmless and it exposes the perforations is possible. Finally, with these cases we
patient to a considerate amount of radiation. Because of reassure the necessity of the surgeon to develop skills to
this, abdominopelvic ultrasound, which reaches an 86% correctly approach a patient with acute abdominal
sensitivity and a 81% specificity, continues to have an syndromes, since the diagnosis might be unsuspected and
important role as a diagnostic tool in a patient with the surgical plan can change in the last minute.
abdominal pain.7 Even though it is a harmless test, it has a
widely known main disadvantage: it is operator Funding: No funding sources
dependent. We must emphasize that these tests are not Conflict of interest: None declared
perfect, and they cannot confirm nor discard the Ethical approval: Not required
diagnosis we are evaluating.
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