By definition, recurrent appendicitis is recurring right lower quadrant pain, similar to previous attacks of pain subsiding after appendectomy. The pathophysiology of recurrent appendicitis is unclear; however, it is thought to be due to the partial or transient obstruction of the appendix. We believe that primary torsion and spontaneous detorsion of the vermiform appendix is one of the etiologies for recurrent appendicitis, which to our knowledge has not been previously described in the medical literature. Herein, we present a case of a 30-year-old male patient with recurrent appendicitis due to primary torsion and spontaneous detorsion of the vermiform appendix treated by laparoscopic appendectomy.

Appendicitis is one of the most common abdominal emergencies encountered by physicians. Acute appendicitis is defined as inflammation of the vermiform appendix which may be followed by gangrene and necrosis of the appendix if not treated. Recently, there have been some reports suggesting that acute appendicitis may resolve either spontaneously or by antibiotic therapy. However, up to 30 percent of patients may present with signs and symptoms suggestive of acute appendicitis. This leads us to an entity called recurrent appendicitis. By definition, recurrent appendicitis is recurring right lower quadrant pain, similar to previous attacks of pain subsiding after appendectomy [1].

A 30-year-old male patient with a history of recurrent right lower quadrant pain since 2 years, episodic in nature with multiple visits to the emergency department and negative workup, presenting currently with similar pain in the right lower quadrant of 3 h duration, nonradiating, and not associated with nausea, vomiting, anorexia, fever, chills, or change in bowel habits. On physical exam, vitals were stable and abdominal exam revealed soft abdomen with no signs of peritonitis, pain was localized in the right lower quadrant with no rebound tenderness. Laboratory workup was normal, with no leukocytosis, no elevated inflammatory markers, and normal urine analysis. CT scan of the abdomen pelvis with IV contrast showed dilated appendix measuring up to 11 mm in diameter with enhancing wall and slightly enlarged mesenteric lymph nodes, no fecalith, and no peri appendicular fat streaking. Given the above, and in view that the patient’s pain was resolved spontaneously, a decision was made for conservative management for the present and scheduling for colonoscopy prior to appendectomy in order to rule out Crohn’s disease. Consequently, colonoscopy was done with no evidence of Crohn’s disease, negative for appendiceal tumor, and no pus or mucus secretions were noted from the appendiceal orifice. Hence, the patient was diagnosed with recurrent appendicitis and was scheduled for laparoscopic appendectomy. Surgery was done using an under vision trocar and two 5-mm trocars. Intraoperatively, the appendix was noted to be thickened and fibrotic, with elongated fan-like mesentery, 120° counterclockwise at the base of the appendix, and the absence of the azygotic folds of the appendix. Detorsion of the appendix was done and the appendiceal artery was controlled using a bipolar electrosurgical device. Two endoloops were placed at the base of the appendix on healthy nonfibrotic tissue; following appendectomy, the appendix was retrieved through an endobag. Postoperative in-hospital stay was smooth with no complications and the patient was discharged on the day of surgery. Pathologic examination showed an intact vermiform appendix measuring 8.5 × 0.8 cm. The serosal surface was erythematous and smooth. The lumen was almost entirely obliterated by the thickened appendiceal wall. The wall was prominently thickened measuring 0.4 cm in thickness. Microscopic exam showing mucosa with regular, columnar cells with basally located nuclei. No intramucosal inflammatory cell infiltrate was noted. Mucosal architecture was preserved (Fig. 1). Below the mucosa was a prominently thickened inner muscle cell layer showing prominent fibrous change (Fig. 2). No granulomas or foreign material was seen. One year after surgery the patient did not experience any right lower quadrant pain similar to that previously described prior to appendectomy.

Fig. 1.

Normal, uninflamed colonic mucosa with an underlying prominent muscle cell layer.

Fig. 1.

Normal, uninflamed colonic mucosa with an underlying prominent muscle cell layer.

Close modal
Fig. 2.

Thickened, fibrous muscle cell layer.

Fig. 2.

Thickened, fibrous muscle cell layer.

Close modal

Although once controversial [1, 2], recurrent and chronic appendicitis is now a well-recognized entity in the medical literature [3, 4]. For diagnosing recurrent appendicitis, a history of similar recurrent right lower quadrant pain requiring appendectomy with complete resolution of symptoms after removal of the appendix is a must.

The pathophysiology of recurrent appendicitis is unclear; however, it is thought to be due to the partial or transient obstruction of the appendix [5, 6]. We believe that primary torsion and spontaneous detorsion of the vermiform appendix is one of the etiologies for recurrent appendicitis, which to our knowledge has not been previously described in the medical literature.

Primary torsion of the appendix has been linked to anatomical variation in the appendix. These variations include a fan-shaped mesoappendix, with a narrow base and the absence of an azygotic fold which is normally attached laterally or along the appendix [7, 8]. The degree of appendiceal torsion varies from 180° to 360°. However, in our case, the degree of rotation leading to torsion was noted to be 90–120°, with a relatively long appendix and fan-shaped mesentery, in addition to the absence of an azygotic fold leading to the torsion of the appendix with possible partial obstruction leading to the accumulation of fluid within the lumen of the appendix, followed by buildup pressure within the appendix leading eventually to a spontaneous detorsion of the appendix and, hence, resolution of the symptoms. On the 1-year follow-up after the surgery, the patient denied any pain similar to that experienced prior to surgery.

From here, as with torsion of any other organ, spontaneous detorsion or untwisting of a torsed appendix can occur, and this condition is worth considering as an etiology for recurrent appendicitis. However, ruling out any other causes of recurrent right lower quadrant pain, especially Crohn’s disease, is of utmost importance. Hence, colonoscopy should be done prior to elective appendectomy for recurrent appendicitis.

Diagnosis of recurrent appendicitis can be a challenge for the unaware. History of recurrent right lower quadrant pain forces most physicians to exclude appendicitis from the differential diagnosis. However, with more evidence supporting recurrent appendicitis as an independent entity, this view needs to be modified. However, as with torsion of any other organ, spontaneous detorsion of a torsed appendix can occur, and this condition is worth considering as an etiology of recurrent appendicitis.

This research complied with the guidelines for human studies and was conducted ethically in accordance with the World Medical Association Declaration of Helsinki. Ethical approval was not required as per hospital guidelines and rules. Written informed consent was obtained from the patient to publish the case as well as all associated images.

The authors have no conflicts of interest to declare.

No funding was received for this study.

All authors contributed equally to the writing and preparation of the article.

All data analyzed in the case report are included in the article. More details are available from the corresponding author upon reasonable request.

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