Transverse colon located appendix: A case of midgut malrotation

Midgut malrotation acut appendicitis

Abstract

Acute appendicitis is the most common cause of abdominal pain requiring general surgical intervention in emergency departments. Its pathogenesis typically involves obstruction of the appendiceal lumen, followed by inflammation, ischemia, and potentially perforation or diffuse peritonitis. The Alvarado score is practical for bedside assessment; however, it does not account for anatomical variations of the vermiform appendix, which may delay diagnosis and increase complication rates. Midgut malrotation results from abnormal or incomplete rotation of the midgut during embryogenesis and may cause an atypically high position of the cecum and appendix. Appendicitis outside the right lower quadrant is associated with higher morbidity and mortality because clinical manifestations are variable and imaging may be inconclusive. We present a 26-year-old male patient admitted with one day of epigastric abdominal pain, nausea, and loss of appetite. Physical examination showed tenderness confined to the epigastrium, and laboratory evaluation revealed leukocytosis. Contrast-enhanced computed tomography did not visualize the appendix in the right lower quadrant and did not report signs suggestive of intestinal malrotation. Because symptoms persisted and pain increased during follow-up, diagnostic laparoscopy was performed within 12 hours of admission. Laparoscopy demonstrated midgut malrotation and an inflamed appendix located adjacent to the transverse colon; laparoscopic appendectomy was completed in the same session. The patient recovered uneventfully and was discharged 24 hours postoperatively, and histopathology confirmed acute appendicitis with localized peritonitis. Diagnostic laparoscopy is a valuable tool in atypical cases when clinical and radiological findings are insufficient, as it enables comprehensive evaluation of the abdominal cavity and allows definitive treatment without delay. In patients with atypical abdominal pain who cannot be diagnosed using conventional pathways, early consideration of congenital anomalies such as midgut malrotation and timely diagnostic laparoscopy are critical to prevent complications.