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Abdominal pain with right iliac fossa tenderness is an extremely common presentation to the general surgical emergency service, with several key differential diagnoses, which may or may not require operative intervention. Appendicitis is very common but may rarely be caused by torsion of the appendix.1
Case history
A 27-year-old man presented to the general surgical emergency clinic with 12 hours of colicky central abdominal pain, bloating, nausea, vomiting and fever. Urinary and bowel habits were unchanged. His only past medical history was mild ulcerative colitis, which was well controlled on mesalazine. He had no significant family history, was a non-smoker and non-drinker.
On physical examination, the patient was pyrexial (temperature 38.4°C) and tachycardic (102bpm) but with otherwise normal cardiovascular and respiratory system examinations. His abdomen was soft; there was tenderness and guarding suprapubically and in the right iliac fossa with a weakly positive Rovsing’s sign, and bowel sounds were normal. Digital rectal examination was unremarkable.
Serum biochemistry and haematology results revealed raised inflammatory markers but were otherwise within normal range. Plain film radiography of the chest and abdomen was unremarkable.
Initial management consisted of administration of intravenous fluid and antibiotic therapy according to local protocols. By the following morning, a reduction in pain and tenderness plus normalisation of the heart rate were observed. In light of this, a further period of observation was undertaken but during this period, the patient’s symptoms worsened and his vital signs became abnormal,...