Year : 2006 | Volume
: 16 | Issue : 4 | Page : 959--960
Radiological quiz - abdomen
C Raychaudhari, HJ Prajapati, HK Shah, R Sheth
Department of Radiology & Imaging, Shri Krishna Hospital, Pramukh Swami Medical College, HM Patel Centre for Medical Care & Education, Gokal Nagar, Karamsad 388325, Anand, Guajarat, India
H J Prajapati
14, Gnandeep Society,Near Shikhodi Talavadi, Anand 388001 Gujarat
|How to cite this article:|
Raychaudhari C, Prajapati H J, Shah H K, Sheth R. Radiological quiz - abdomen.Indian J Radiol Imaging 2006;16:959-960
|How to cite this URL:|
Raychaudhari C, Prajapati H J, Shah H K, Sheth R. Radiological quiz - abdomen. Indian J Radiol Imaging [serial online] 2006 [cited 2019 Nov 13 ];16:959-960
Available from: http://www.ijri.org/text.asp?2006/16/4/959/32400
A sixty-two year female patient came to hospital with chief complains of epigastric pain, vomiting and fever since last two days. Ultrasonography of abdomen was performed and following is the pictures of USG in the region of the epigastrium. What is your diagnosis?
View AnswerSUBHEPATIC APPENDICITIS
Ultrasonographic picture in the epigastrium showed blind ending, tubular, thick walled, nonperistaltic structure with seven millimeters diameter seen in epigastrium under the left lobe of the liver. Due to the typical picture of appendix, diagnosis of acute appendicitis in the epigastric region below the left lobe of liver. Than the patient was operated and below the left lobe liver, inflamed appendix was found and caecum was in the left lumber region. So there was malrotation of the mesentery and large bowel loops were on the left side. Appendicectomy was performed and fixation of the large bowel was done.
A knowledge of intestinal embryology is helpful in understanding intestinal malrotation. The midgut is defined as that segment of the intestine supplied by the superior mesenteric artery and extending from the duodenum to the distal portion of the transverse colon. Until the fifth week of development, the midgut is a straight tube. During the fifth week, the sequence of rotation begins. The first stage of rotation occurs between the fifth and tenth weeks of gestation and involves the migration of the midgut from the abdominal cavity or umbilical sac. The midgut rotates 90 degrees counterclockwise as it returns to the abdominal cavity. In the second stage, which occurs in the 11th week of gestation, the midgut rotates an additional 180 degrees counterclockwise within the abdominal cavity. This brings the cecum to a subhepatic location. At the end of this stage, the duodenum is behind the transverse colon, which lies in front of the superior mesenteric artery. Anomalies that may occur during this stage are nonrotation, malrotation and reversed rotation.The cecum lies in the midline /right upper quadrant.The third stage of midgut development lasts from the 12th to the 20th week of gestation. During this period, the cecum descends into the right lower quadrant, with fixation of the large and small bowel mesentery. 
The malrotation in this case is an example of developmental arrest in the early part of the second stage of midgut development. An estimated 0.2 to 0.5 percent of the adult population have malrotation. 
Anatomic variations in the location of the appendix are often responsible for delays in the diagnosis of appendicitis.  Midgut malrotation is a developmental anomaly that may cause atypical clinical symptoms in relatively common intestinal disorders due to altered anatomy. 
The examining physician should maintain a high index of suspicion for appendicitis in a patient with signs and symptoms of appendicitis and atypical location of pain.
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