S Karuppiah, A Dhaliwal
abdominal pain, acute appendicitis, analomous band, congenital band
S Karuppiah, A Dhaliwal. Analomous congenital band mimicking acute appendicitis: A case report. The Internet Journal of Emergency and Intensive Care Medicine. 2007 Volume 11 Number 2.
Acute appendicitis is a common abdominal pathology presenting to the emergency department. An accurate diagnosis in the early stage is often difficult and the incidence of misdiagnosis, due other pathologies causing similar clinical signs, is very high. We present a rare case of congenital band mimicking acute appendicitis.
Acute appendicitis represents the most frequent cause of surgical acute abdomen in emergency units. Sometimes other abdominal pathology, such as renal colic, salphingitis, and coeliac disease may also present as abdominal pain and can mimic signs and symptoms of acute appendicitis.
Congenital bands present as intestinal obstruction occurring mostly in children at known anatomical sites such as Meckels diverticulum, ligament of Trietz and remnants of vitelline duct (1,2). The incidence of congenital band is less than 1% in a given population and congenital band presenting as pain in the right iliac fossa, mimicking signs and symptoms of acute appendicitis, have never been reported before.
A 23 year old female patient presented to Accident & Emergency department with 48 hours history of abdominal pain which initially started at her umbilical region and later radiated to her right iliac fossa. She had associated symptoms of nausea and loss of appetite. There was no history suggestive of renal colic, urine infection, ectopic pregnancy or pelvic inflammatory disease.
On examination she was pyrexial at 38.2 degree centigrade with pulse of 110/min. Her vitals were otherwise stable. She was tender in the right lower quadrant of her abdomen with guarding and rebound tenderness at McBurney's point. Bowel sounds were absent. Per rectal examination was otherwise normal.
Laboratory investigations showed mild leucocytosis at 14x10 3 (normal range 7x10 3 – 10x10 3 ), Neutrophil 9x10 3 (normal range 1.8x10 3 – 7x10 3 ). Urine analysis and urine pregnancy test was negative. AP Abdominal radiograph was unremarkable
She was referred to the surgical team and subsequently underwent laparoscopy for suspected acute appendicitis. Intra operatively a congenital band was found, originating from the right ileum to the tip of the appendix, ‘tugging' on the appendix under tension. The appendix was otherwise normal (Figure 1). The band was excised laparoscopically using bipolar diathermy. Post operatively her symptoms settled and she was discharged with no complications.
Abdominal bands presenting without previous laparotomy or intraperitoneal inflammation has been termed as “congenital band”, but there are very little details about these medical textbooks. Touloukian was the first to describe about congenital bands causing small bowel obstruction in significant detail (1). Some reports have also shown evidence of chronic abdominal pain and failure to thrive (3,4), due to congenital bands, with majority of these symptoms mainly occurring in children and rarely presenting beyond 6 years of age (1,5). The obstructions mainly localized to the terminal ileum and colon (1,2,3). However patients usually present with signs and symptoms of bowel obstruction and a thorough review of literature shows no evidence congenital band presenting as acute appendicitis.
This patient did not have any previous operations and operative findings showed no other abnormal inflammatory adhesion bands between the small and large intestines.
Its localization excluded known embryogenic remnants, such as vitelline arteries or veins or omphalomesenteric ducts or mesourachus (6,7). The most likely explanation is described by Akgur et al (1), is that this band originated from a mesenteric anomaly. At about the 28th day of intrauterine life, transiently, the dorsal and ventral mesenteries divide the peritoneal cavity into right and left halves, but the ventral mesentery soon disappears, except around the liver and in front of the stomach (8). As the intestines assume their final positions, their mesenteries are pressed against the posterior abdominal wall. The anomalous congenital band in our case was considered to be the remnant of ventral mesenterium that failed to reabsorb completely. The anatomical location of the congenital band could easily explain the signs and symptoms of this patient. The band arising from the tip of the appendix under tension caused stretching of the peritoneum causing pain distribution similar to acute appendicitis.
Reports concerning intestinal congenital bands are sporadic (1,2,3). These symptoms are relieved with band excision and no bowel resection is required if patients are treated before vascular supply is compromised as in our case. Early and prompt surgical intervention resulted in minimal operative intervention for this patient.
The accurate diagnosis for the cause of acute abdominal pain remains a challenge in emergency care. High index of suspicion must be borne in mind about other rare causes that can mimic common pathologies such as acute appendicitis.
Mr S Karuppiah
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