Archives of International Surgery

: 2017  |  Volume : 7  |  Issue : 4  |  Page : 139--141

Surgeons beware: It may not be acute appendicitis

AA Iloh, SO Omorogbe, OC Osime 
 Department of Surgery, University of Benin Teaching Hospital, Benin-City, Nigeria

Correspondence Address:
Dr. A A Iloh
Department of Surgery, University of Benin Teaching Hospital, P.M.B 1111, Benin-City, Edo State


Acute appendicitis may mimic several acute abdominal conditions. In perforated peptic ulcer disease, the contents may track down the right iliac fossa to mimic the presentation of acute appendicitis. The objective of this study was to highlight the diagnostic dilemma encountered in differentiating perforated peptic ulcer (with gastric contents tracking into the right iliac fossa) and acute appendicitis. We present the case of a 45-year old man who had appendicectomy in a private medical center and later developed features of generalized peritonitis 10 days after surgery. Following a diagnosis of postoperative peritonitis, exploratory laparotomy was carried out, which revealed perforated gastric ulcer. The perforation was repaired and peritoneal lavage was done. He made an uneventful recovery and was discharged after 3 weeks on admission. Perforated peptic ulcer could mimic acute appendicitis. A high index of suspicion is vital in differentiating both conditions, to prevent the morbidity and mortality resulting from misdiagnosis.

How to cite this article:
Iloh A A, Omorogbe S O, Osime O C. Surgeons beware: It may not be acute appendicitis.Arch Int Surg 2017;7:139-141

How to cite this URL:
Iloh A A, Omorogbe S O, Osime O C. Surgeons beware: It may not be acute appendicitis. Arch Int Surg [serial online] 2017 [cited 2020 Sep 20 ];7:139-141
Available from:

Full Text


Acute appendicitis is the most frequently diagnosed acute surgical abdominal condition.[1],[2] Several abdominal conditions may mimic this pathology. One of such conditions that can present as acute appendicitis is perforated peptic ulcer disease (PUD), with the contents tracking down to the right iliac fossa through the right paracolic gutter causing periappendiceal inflammation.[3],[4] This rare condition, known as Valentino's syndrome, is characterized by right lower quadrant pain, usually diagnosed at surgery.[5] At appendicectomy in such patients, the appendix is uninflamed but with surrounding turbid or bilous peritoneal fluid that necessitate a formal laparotomy or laparoscopy to manage the perforation.[6]

Delay in diagnosis and treatment of perforated PUD is associated with high morbidity and mortality.[7] Misdiagnosis under this setting can be a ground for litigation with respect to misdiagnosis. We present a case of perforated gastric ulcer that was initially managed as acute appendicitis to reawaken the awareness that this condition still exists in medical practice today.

 Case Presentation

A 45-year-old man was referred from a private medical center where he had appendicectomy for complaints of right iliac fossa pain. He presented to the emergency department with generalized abdominal pain and distention of 10 days duration, developed 3 days after the surgery. There was no formal report on the nature of the appendix at surgery. The patient had a sudden epigastric pain that radiated to the right iliac fossa a day prior to the appendicectomy. There was associated bilious vomiting and fever and a history of chronic alcohol ingestion, but no recurrent upper abdominal pains or chronic nonsteroidal antiinflammatory drug (NSAID) ingestion.

On examination, he was tachycardic, dehydrated, febrile, with a grossly distended abdomen that moved minimally with respiration, a healed Lanz incision scar, generalized tenderness with guarding and ascites. Bowel sounds were hypoactive. Rectal examination showed tenderness and bogginess in the rectovesical pouch. Laboratory investigations revealed white blood cell count of 15,900 cells/mm with neutrophilia of 79%, hemoglobin of 10.8 g/dl, and platelet count of 155,000 cells/mm. There was hypokalemia of 3.0 mmol/l, while urea and other electrolytes were normal. Abdominal ultrasonography revealed free fluid in the peritoneal cavity with features of paralytic ileus. Following a diagnosis of generalized peritonitis, he was resuscitated and had emergency laparotomy with findings of 5 litres of purulent peritoneal collection with a 0.3 cm anterior perforation in the prepyloric region of the stomach. The pus was suctioned and biopsy of the edge of the perforation was done, which showed benign features. A two-layer repair with vicryl 2/0 was done. Peritoneal cavity was irrigated with normal saline and a subhepatic and pelvic closed tube drains inserted. Postoperatively, he was placed on antibiotics, analgesics, proton pump inhibitors, intravenous fluids, and amino acids. However, he had persistent drainage of bilious fluid from the drains, which later became seropurulent and was managed conservatively until drainage became insignificant 2 weeks postoperatively, following which the drains were removed and oral intake commenced. He was then placed on Helicobacter pylori eradication therapy. He also developed superficial surgical site infection that was treated with daily wound dressings. Patient was discharged in a stable condition after 3 weeks on admission for follow-up with an upper gastrointestinal endoscopy.


Acute appendicitis typically presents initially as a dull periumbilical pain, which later shifts to the right iliac fossa, but atypical presentations could depend on the location of the inflamed appendix.[8] Perforated peptic ulcer disease is a major cause of acute abdomen in our environment.[7] Clinical presentation is usually a young man with a history of chronic NSAID or alcohol ingestion and a previous history of intermittent burning epigastric pain related to meals, presenting with a sudden sharp epigastric pain that becomes generalized. However, there are atypical presentations that could mimic acute appendicitis.

Valentino's syndrome was named after Rudolph Valentino, an American actor who in 1926 died after surgery for perforated PUD, which mimicked acute appendicitis on presentation. Few cases have been reported in the literature.[3],[4],[5],[6],[9] In this rare condition, the duodenal or gastric contents track down to the right paracolic gutter either through the subhepatic space or retroperitoneally,[5] and incites periappendiceal peritoneal inflammation.[10] This condition is then misdiagnosed as acute appendicitis. Moreover, some patients with perforated PUD may not have a previous history of dyspepsia and may not admit a history of sudden onset of epigastric pain, which later shifted to the right iliac fossa.[7] They may be more concerned with the right iliac fossa pain during presentation, hence are diagnosed as having acute appendicitis. Acute appendicitis has long been a clinical diagnosis, especially in developing countries that lack adequate and modern radio-diagnostic facilities.

Preoperatively, Valentino's syndrome can be confirmed by computed tomography (CT) scan. Only two preoperatively confirmed cases have been reported in the literature.[5],[11] However, a good ultrasound scan has been shown to diagnose cases of perforated peptic ulcer presenting as acute appendicitis.[12] Characteristic features on CT imaging include air in the retroperitoneum on the right side, predominantly around the right kidney (“veiled right kidney” sign) with normal renal parenchyma, fat stranding and retroperitoneal air in and around the region of the duodenum, and duodenal wall thickening.[13] The role of laparoscopy should be emphasized in cases of diagnostic dilemma as it also aids in placing an appropriate incision when the procedure cannot be completed laparoscopically. Delay in diagnosis and intervention increases the morbidity and mortality in such patients. There is an increased risk of complications such as breakdown of repair, surgical site infection, and wound dehiscence, with increased hospital stay and cost of care.

In conclusion, perforated peptic ulcer can have atypical presentation mimicking other causes of acute abdomen such as acute appendicitis. A detailed history, physical examination, and radiological investigations should differentiate both conditions in majority of cases. However, surgeons carrying out an appendicectomy from a right iliac fossa incision should suspect perforated peptic ulcer if there is bile stained or turbid peritoneal fluid in the absence of an inflamed appendix.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient has given his consent for his images and other clinical information to be reported in the journal. The patients understand that his names and initials will not be published and due efforts will be made to conceal his identify, but anonymity cannot be guaranteed.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.


1Agboola JO, Olatoke SO, Rahman GA. Pattern and presentation of acute abdomen in a Nigerian teaching hospital. Niger Med J 2014;55:266-70.
2Obonna GC, Arowolo OA, Agbakwuru EA, Etonyeaku AC. Emerging pattern of emergency abdominal surgeries in Ile-Ife, Nigeria. Niger J Surg Sci 2014;24:31-5.
3Osime OC, Momoh MI. Perforated duodenal ulcer presenting as acute appendicitis. Sahel Med J 2008;11:52-6.
4Sultan R, Pal KMI. Valentino appendix: A report of 3 cases. J Pak Med Assoc 2015;65:223-4.
5Mahajan PS, Abdalla MF, Purayil NK. First report of preoperative imaging diagnosis of a surgically confirmed case of Valentino's syndrome. J Clin Imaging Sci 2014;4:28.
6Wijegoonewardene SI, Stein J, Cooke D, Tien A. Valentino's syndrome; a perforated peptic ulcer mimicking acute appendicitis. BMJ Case Rep 2012;2012.pii: bcr0320126015.
7Ugochukwu AI, Amu OC, Nzegwu MA, Dilibe UC. Acute perforated peptic ulcer: Our clinical experience in an urban tertiary hospital in south east Nigeria. Int J Surg 2013;11:223-7.
8Liang MK, Andersson RE, Jaffe BM, Berger DH. The appendix. In: Brunicardi FC, Andersen DK, Billar TR, Dunn DL, Hunter JG, Matthews JB, et al, eds. Schwartz's principles of surgery. 10th ed. New York: Mc Graw Hill education; 2014. p. 1241-62.
9Blundell S, Campbell A, Patel R, Besarovic S. Valentino's syndrome in an adolescent boy with peptic ulcer perforation simulating acute appendicitis. J Paediatr Surg Special 2015;9:40-2.
10Durai R, Hoque H, Ng P. The acute abdomen- Commonly missed and mis-diagnosed conditions: Review. Webmed Central Surg 2010;1:WMC001036.
11Wang HP, Su WC. Images in clinical medicine. Veiled right kidney sign in a patient with Valentino's syndrome. N Engl J Med 2006;354:e9.
12Ooms HW, Koumans RK, Ho You PJ, Puylaert JB. Ultrasonography in the diagnosis of acute appendicitis. Br J Surg 1991;78:315-8.
13Hsu CC, Liu YP, Lien WC, Lai TI, Wang HP. A Pregnant woman presenting to the ED with Valentino's syndrome. Am J Emerg Med 2005;23:217-8.