A twist in diagnosis

A 52-year-old male weighing 74 kg presented with a twoday history of colicky pain in the supra-umbilical region. He complained of nausea and anorexia. On the day of presentation, his pain migrated to the right iliac fossa and became constant. Examination revealed a pulse of 90 bpm with a temperature of 98.7 F. He was found to be tender in the right iliac fossa with voluntary guarding and rebound. His white cell count was found to be 11.3 per m with a shift in the neutrophils to the left. His MANTREL score was estimated at 9. A mini-Lanz incision approach for appendicectomy was performed. Serosanguineous peritoneal fluid was noted on entering the cavity. The appendix was macroscopically noninflamed. Intraperitoneal ischemia was suspected at this time, and on mobilization of the intraperitoneal contents, a 1080 torsion of a 8 10 cm lip of omentum was noted (Fig. 1). The ischemic segment was excised between ligatures. An incidental appendicectomy was performed. The patient recovered uneventfully.