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Valentino Syndrome: Perforated Peptic Ulcer Masquerading as Acute Appendicitis

Karina Castillo*, Katty Coronel, Jenny Coronel

General Surgery Service, Guayaquil Specialty Hospital Dr. Abel Gilbert Pontón. Guayaquil, Ecuador

Abstract: Abdominal pain is a common symptom in gastrointestinal diseases. It occurs through different mechanisms and its location usually guides us in making differential diagnoses. Valentino syndrome is a pathology that presents with atypical symptoms that simulate acute appendicitis. We present the case of a 30-year-old male patient presented with pain in the right iliac fossa. Given the clinical suspicion of acute appendicitis and the laboratory and imaging findings, exploratory laparotomy was performed. Since no inflammatory changes were evident in the appendix, it was decided to perform a thorough abdominal examination, and an important finding was a gastric perforation, where the gastric and duodenal fluids traveled through the paracolic gutter, being located in the right lower quadrant and causing focal peritonitis.This syndrome, given its genesis and inadequate management, should be given special importance and maintained as a differential diagnosis due to the considerable mortality it entails.

Keywords: abdominal pain, acute abdomen, appendicitis, peptic ulcer, Valentino syndrome.

Received December 15, 2023; Revised January 17, 2024; Accepted January 24, 2024

Citation: Karina Castillo, Katty Coronel, Jenny Coronel, Valentino Syndrome: Perforated Peptic Ulcer Masquerading as Acute Appendicitis. Global Journal of Surgery, 12 (1). 1-3. January 2024. doi:10.12691/js-12-1-1

1. Introduction

Abdominal pain is one of the most common symptoms for which people go to the emergency services, and this symptom can be one of the forms of presentation of various disorders of different severity and treatment [1].

Pain in the right iliac fossa caused by the passage of gastric and duodenal contents through of the right parietocolic space and which causes peritoneal inflammation is called Valentino Syndrome [2,3].

It received this name from the American actor Rudolph Valentine (1895-1926), who was initially named he had diagnosed acute appendicitis and underwent surgery, finding a normal appendix. He later developed peritonitis and multiple organ failure until his death. The autopsy revealed a perforated gastric ulcer [4,5].

Since then, this eponym has been used to mention this unusual clinical presentation that resembles appendicitis [5].

2. Case Report

A 30-year-old male patient, a user of a narcotic substance (cocaine), went to the emergency service complaining of progressive abdominal pain for 4 days, initially located in the mesogastrium that later migrated to the right iliac fossa, associated with nausea, vomiting, unquantified thermal and hyporexia.

Physical exam: BP: 120/70 mmHg, HR: 68 x´, RR: 26 x´, T: 38.5°C

Abdomen: Distended, painful on palpation in the right iliac fossa, positive signs of peritoneal irritation (Mc Burney, Blumberg, Rovsing, Guéneau de Mussy).

Laboratory: Leukocytes 14,000 cells/mm3, Neutrophils 72%, Hb: 12.9 g/dl, Hct: 36.8%, PT: 16,9 "s", TTP: 36 "s", INR 1.4.

A postero-anterior chest x-ray was performed (Figure 1) showing veiling of the left cardio- and costophrenic angle and elevation of the hemidiaphragm; standing abdominal x-ray showing distended loops.

Due to the clinical characteristics, physical examination and complementary examinations, it was classified as acute inflammatory abdomen due to acute appendicitis. The patient was not requested an ultrasound based on the fact that the diagnosis of appendicitis is clinical and because ultrasound is operator dependent and could cause confusion in the diagnosis. Abdominopelvic tomography could not be performed because the equipment was under maintenance.

An exploratory laparotomy was performed where 600cc of fibrino-purulent fluid was observed in the right parietocolic gutter and rectovesical space and retrocecal appendix without inflammatory changes. After exhaustive exploration of the abdominal cavity, the presence of a fibrinous plaque was found in the middle third of the anterior surface of the stomach, which covered a peptic ulcer approximately 2 cm in diameter (Figure 2).

Figure 1. PA chest x-ray with visualization of the left cardio- and costophrenic angle, elevation of the hemiadiaphragm

Figure 2. Simple abdominal x-ray with distended loops

Figure 3. Perforated prepyloric ulcer, 2 cm in diameter

The surgical procedure was completed with primary raffia plus omentum patch after taking a sample for pathology, washing and placing drains in the operating bed. After surgery, the patient was admitted to the ward, had a favorable evolution and was discharged after 8 days with a psychological and psychiatric evaluation due to his dependence on narcotics.

3. Discussion

Valentino Syndrome occurs due to the perforation of a peptic ulcer, this being a rare complication (10%), accumulation of gastrointestinal fluids in the right iliac fossa generating diffuse peritonitis [3].

Currently there are no conclusive epidemiological data on its incidence, prevalence or other statistical data [4]. The study on the topic has been carried out on series of cases, collecting isolated experiences and analyzing the experience acquired.

The reported case has similar clinical presentations with those already reported where it appeared to be acute appendicitis and for this reason they were taken to the operating room, establishing the diagnosis intraoperatively, because there was no there is appendiceal involvement, but if the presence of free purulent fluid requires an exhaustive abdominal examination, perforated peptic ulcers with unusual clinical presentation are observed [2,3,6]

In all cases, imaging studies were performed, identifying pneumoperitoneum and free fluid in the abdominal cavity. It is worth mentioning that in the present case only chest and abdominal X-rays were performed, where were evident veiling of the left cardio- and costophrenic angle, elevation of the hemidiaphragm and distended loops. Due to the symptoms compatible with appendicitis, it was decided to address the problem surgically.

In most of the reported cases, perforated ulcers were managed with primary raffia with Graham patch [7], while others only with Graham patch. In this case, primary raffia with a Graham patch was performed, which remains the “Gold Standard” for the treatment of perforation of a hollow viscus [3].

4. Conclusion

In conclusion we can mention that a perforated peptic ulcer can cause a clinically subjective picture of acute appendicitis due to its great clinical similarity. Valentino syndrome, being a rare entity and associated with high morbidity and mortality, requires special importance in both diagnosis and treatment. Consider it within the differential diagnosis of those patients with signs suggestive of acute abdomen to reduce diagnostic error, possible complications and, therefore, patient morbidity and mortality.

Conflict of Interest Statement

The authors declare that they have no conflicts of interest.

References

[1]   | Artigas, O. Abdominal pain in the emergency room. Comprehensive Med. 2002, 40(9): 379-85.
[2]   | Fretes D, Martínez A, Fernández U, Benítez M, Cardozo R. Valentino syndrome. Perforated peptic ulcer. Cir. Parag. 2018; 42(3): 40-41.
[3]   | Santafe-Guerrero M, Cabrera-Vargas L, Aparicio-Blanco B, Pérez-Rivera C, Pedraza-Ciro M, Valentino syndrome, current management of a forgotten disease. Annals of Mediterranean Surgery. 2021; 4(2): 03-09.
[4]   | López-Beltrán J, Orbea-Marcial Víctor, Cadena-Garcés Gabriela, Villagrán-Morales S, Pozo-Espín D. Rev UNIANDES Health Sciences. 2021; 4(1): 637-662.
[5]   | Arumugam B, Giridharan B, RP, P S. Syndrome Valentino From a De Novo Aetiology – Acute Pancreatitis. Cureus. 2022; 14(1): 02-06.
[6]   | Mahajan PS, Abdulmalek H, Aljafari A, Kolleri J, Dawsi S, Mohammed H. A Cautionary Tale: Unveiling Valentino's Syndrome. 2022; Cureus 14(2): 02-09.
[7]   | Veintimilla-Hurtado J, Rivas-Ullaguari A, Quito-Becerra A, Patiño-Cuenca V, Castillo-Andrade Y. Valentino syndrome: a rare cause of acute abdomen. Report of a case. HJCA Medical Journal. 2020; 2(3): 231-35.