Rare Case Report: Partial Situs Inversus with Intestinal Malrotation and Perforated Appendicitis with Generalized Peritonitis in a 65-Year-Old Male

Rare Case Report: Partial Situs Inversus with Intestinal Malrotation and Perforated Appendicitis with Generalized Peritonitis in a 65-Year-Old Male | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Rare Case Report: Partial Situs Inversus with Intestinal Malrotation and Perforated Appendicitis with Generalized Peritonitis in a 65-Year-Old Male Nigussie Tesfaye Gizaw, Endashew Menberu, Sinbona Ararsa, Tesfaye Bekele, and 3 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-7631775/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract A male patient, age 65, arrived at the emergency room of Ambo University Referral Hospital in Ambo, Ethiopia, complaining of severe, diffuse abdominal discomfort that had persisted for three days. The patient also had fever, nausea, and distension in his abdomen. After starting in the lower left quadrant, the discomfort gradually spread throughout the entire abdomen. Intestinal malrotation, usually diagnosed in infancy, which results from incomplete rotation of the midgut during embryogenesis. Adult presentation is rare and often incidental or complicated by obstruction or volvulus. It emphasizes the importance of considering congenital anatomical variants in adults with atypical abdominal pain, and the need for early imaging to guide timely surgical intervention. Figures Figure 1 Figure 2 Figure 3 Figure 4 Figure 5 Figure 6 Introduction Appendicitis usually manifests acutely within 24 hours and is defined by inflammation of the vermiform appendix [1]. Appendicitis remains one of the most common surgical emergencies faced by the surgeon in the surgical department [2]. The typical presentation of acute appendicitis is characterized by fever, anorexia, and peritoneal response upon examination, along with periumbilical pain spreading to the right lower quadrant of the abdomen [3]. However, unusual clinical manifestations have been documented, including back pain, lower abdominal quadrant discomfort, particularly in situs inverus, left flank or left hypochondrium pain, and intestinal malrotation [4]. Midgut malrotation (MM) and situs inversus (SI) are rare anatomic abnormalities that make diagnosing and treating acute abdominal pain more difficult [5] [6]. Situs inversus is a rare congenital condition that produces a "mirror image" by transposing the abdominal organs, viscera, and vasculature with respect to the sagittal direction. While partial situs inversus only affects one or more organs, totalis situs inversus is defined as involving dextrocardia [7] [8]. A fetal abnormality known as midgut malrotation arises when the superior mesenteric artery's axis fails to rotate, and this is followed by retroperitoneal fixation. With an approximate incidence of one in 500 live births, it is a rare disorder [3] [5] . According to estimates, 85% of cases manifest during the first two weeks of life [5]. Acute appendicitis is still the most common reason for gastrointestinal surgical emergency procedures, and it is typically easy to diagnose. When the appendix is malpositioned, diagnostic ambiguity may arise because acute appendicitis does not always appear in the same way. Located 2.5 cm behind the ileocecal valve on the posterio-medial part of the cecum, the appendix is a vestigial organ [9]. The anatomical position of this organ is the only one that varies across the body. The retrocecal, pelvic, subcecal, preileal, and postileal are among the different placements; less frequently observed are subhepatic, mesoceliac, intrahernial (femoral or inguinal), and left-sided [6] [2]. The appendix is a blind-ending structure anatomically [9]. In cases of extreme severity, a closed-loop blockage of its lumen causes inflammation and transmural necrosis, which ultimately result in peritonitis and the perforation and release of the luminal contents (pus and fecaliths) [10]. Acute appendix perforation is a dangerous side effect of appendicitis that is linked to higher rates of morbidity and death. Extremes of age, male gender, pregnancy, immunosuppression, coexisting medical conditions, and previous abdominal procedures are risk factors for perforated appendicitis [8]. While it varies, the incidence of macroscopic appendiceal perforation in large series is approximately 20–30%. Generalized peritonitis or localized walled-off accumulations of pus (appendix abscess) are the next steps after an appendiceal perforation. Approximately 20% of children with acute appendicitis have a fecolith. Pseudomonas aeruginosa, Peptostreptococcus species, Fusobacteria, Escherichia coli, and Bacteroides fragilis are among the common bacterial isolates seen in perforated appendicitis [9] [11]. Adults rarely exhibit situs inversus, particularly those who have no complaints. Situs inversus is diagnosed incidentally with other entities such as appendicitis or cholecystitis [12] . The incidence of situs inversus is 0.001% to 0.01% of the general population [12]. Therefore, it is challenging to determine an exact incidence because this problem may go undiagnosed and asymptomatic until it is found during adult tests or surgery for other gastrointestinal pathologies. Due to intestinal malrotation's rarity, clinical suspicion of the condition decreases with age. We report a case of partial situs inversus with intestinal malrotation and perforated appendicitis with generalized peritonitis in 65-year-old male. Case Presentation A 65-year-old male patient presented to the emergency department of Ambo University Referral Hospital, Ambo, Ethiopia with a severe, diffuse abdominal pain of 3 days' duration, associated with fever, nausea, and abdominal distension. The pain initially began in the left lower quadrant and progressively worsened to involve the entire abdomen. The patient denied any history of past abdominal surgery, medical illnesses, or injuries to the abdomen. He reported as drinker in social situations, but he had no prior medical history of asthma, diabetes, hypertension, or similar conditions. Clinical findings and Physical examinations During physical examination the patient’s vital signs were: temperature of 38.8°C, pulse rate of 112 beats per minutes, Blood Pressure of 95/60 mmHg and a respiratory rate of 20 breadths per minute. Abdominal examination revealed: there was abdominal distension, rebound tenderness and guarding across all quadrants, hypoactive bowel sounds and the digital rectal examination revealed that there was empty rectum; tenderness on right side of pelvis. Laboratory and Radiological Investigations Laboratory tests showed leukocytosis with neutrophil predominance. Abdominal X-ray and abdominal CT- scan with Contrast were ordered. Abdominal X-ray showed free air under diaphragm and abdominal CT- scan revealed cecum and appendix located in the left lower quadrant, sigmoid colon positioned in the right iliac fossa, duodenojejunal junction on the left side but not crossing midline, and signs of free intraperitoneal air and fluid, with inflamed, perforated appendix at midshaft, surrounded by fecal contamination. Finally the patient was diagnosed with partial situs inversus with intestinal malrotation complicated by perforated midshaft appendicitis and generalized peritonitis. Intraoperative Findings Exploratory Laparatomy of abdominal cavity was done with a minimally disruptive approach. Then the peritoneal cavity was explored showing a partial situs inversus in which transverse colon and sigmoid colon displaced to the right, small bowel and cecum to the left. Regarding the malrotation, the bowel was unfixed with narrow mesenteric base, perforation at the midshaft of the appendix with fecal contamination, and generalized purulent peritonitis. Ladd’s procedure was performed to correct malrotation, and appendectomy was done with peritoneal lavage and drainage. Discussion This is a rare and complex case of partial situs inversus and intestinal malrotation in an elderly male, presenting for the first time with perforated appendicitis and diffuse peritonitis. This case is particularly unusual due to: the appendix being located in the left lower quadrant, perforation at the midshaft, rather than the tip or base and coexistence of partial situs inversus and malrotation, both congenital and rarely symptomatic in adulthood. Situs inversus is a congenital condition involving reversal of visceral organ positioning; partial situs inversus refers to an incomplete mirror-image anatomy [ 13 ]. Intestinal malrotation, usually diagnosed in infancy, which results from incomplete rotation of the midgut during embryogenesis. Adult presentation is rare and often incidental or complicated by obstruction or volvulus [ 14 ]. Appendicitis in malrotation and situs inversus is notoriously difficult to diagnose preoperatively due to atypical pain localization, often delaying diagnosis and increasing the risk of complications such as perforation and peritonitis [ 15 ]. Conclusion This is a rare and life-threatening case of perforated midshaft appendicitis with generalized peritonitis in a patient with partial situs inversus and intestinal malrotation. It emphasizes the importance of considering congenital anatomical variants in adults with atypical abdominal pain, and the need for early imaging to guide timely surgical intervention. Declarations Disclosure of ethics statement The patient gave written informed consent for this case report and any related photos to be published. In order to undertake all procedures in compliance with applicable rules and legislation to protect human subjects and their data, a formal informed consent form was read and signed. All patient information was kept private. Participants' names and other personal information were kept private. Conflict Interest The authors declared no conflict of interest. Funding The authors did not receive any specific funding for this work. Author Contribution N.T. wrote the main manuscript and E.M, S.A,T.B, K.M and I.G done the surgical procedure and read the radiological findingsK.N reviewed the main manuscript Acknowledgement We express a debt of gratitude to the patient and all those involved in this case report for its publication Data Availability The authors did not receive any specific funding for this work. References Lotfollahzadeh S, Lopez RA, Deppen JG. Appendicitis, in StatPearls [Internet] , StatPearls Publishing, 2024. Accessed: Sept. 05, 2025. [Online]. Available: https://www.ncbi.nlm.nih.gov/books/NBK493193/ Sabiston DC, Townsend CM, Beauchamp RD, Evers BM, Mattox KL, editors. Sabiston textbook of surgery: the biological basis of modern surgical practic , 20th edition. Philadelphia, PA: Elsevier, 2017. A Rare case. of Intestinal Malrotation presenting as Appendicitis in Late Adulthood. J Surg Case Rep. Oct. 2010. 10.1093/jscr/2010.8.3 . Krzyzak M, Mulrooney SM. Acute Appendicitis Review: Background, Epidemiology, Diagnosis, and Treatment. Cureus. June 2020. 10.7759/cureus.8562 . Lord Mvoula T, Khrisat, Lueders M. A Case of Left-Sided Acute Appendicitis in a 45-Year-Old Man with Situs Inversus Totalis Managed by Emergent Laparoscopic Appendectomy, Am. J. Case Rep. , vol. 25, Jan. 2024, 10.12659/AJCR.942323 Akbulut S, Caliskan A, Ekin A, Yagmur Y. Left-sided Acute Appendicitis with Situs Inversus Totalis: Review of 63 Published Cases and Report of Two Cases, J. Gastrointest. Surg. , vol. 14, no. 9, pp. 1422–1428, Sept. 2010, 10.1007/s11605-010-1210-2 Carvalho BCU et al. Situs inversus: anatomical and clinical study, Res. Soc. Dev. , vol. 11, no. 16, pp. e434111638410–e434111638410, 2022, Accessed: Sept. 05, 2025. [Online]. Available: https://scholar.archive.org/work/bzgd3luqgbhwtfwoeatri3dbpi/access/wayback/https://rsdjournal.org/index.php/rsd/article/download/38410/31806 Abebe WM, Workalemahu DM, Leta RA, Asefa MA, Alemu HT, Molla YD. Left-sided perforated appendicitis in a patient with situs inversus totalis, a case report, SAGE Open Med. Case Rep. , vol. 12, p. 2050313X241266522, Jan. 2024, 10.1177/2050313X241266522 Bhat S. SRB’s Manual of Surgery . Jaypee Brothers Medical Publishers, 2019. Accessed: Sept. 05, 2025. [Online]. Available: https://books.google.com/books?hl=en&lr=&id=P3KSDwAAQBAJ&oi=fnd&pg=PR1&dq=SRB%27s+manual+of+surgery&ots=n09q4hr7NH&sig=Qwm3_ZrdXhHH2-x1qmkTpKybIpo Balogun OS, Osinowo A, Afolayan M, Olajide T, Lawal A, Adesanya A. Acute perforated appendicitis in adults: Management and complications in Lagos, Nigeria, Ann. Afr. Med. , vol. 18, no. 1, pp. 36–41, 2019, Accessed: Sept. 05, 2025. [Online]. Available: https://journals.lww.com/aoam/fulltext/2019/18010/acute_perforated_appendicitis_in_adults_.7.aspx Stringer MD. Acute appendicitis. J Paediatr Child Health. Nov. 2017;53(11):1071–6. 10.1111/jpc.13737 . An Unusual Case of Perforated Appendicitis in Situs Inversus Totalis in Indonesia,. New Ropanasuri J Surg. June 2022;7(1). 10.7454/nrjs.v7i1.1117 . Nehra D, Goldstein AM. Intestinal malrotation: Varied clinical presentation from infancy through adulthood, Surgery , vol. 149, no. 3, pp. 386–393, Mar. 2011, 10.1016/j.surg.2010.07.004 Haak BW, Bodewitz ST, Kuijper CF, de Widt-Levert LM. Intestinal malrotation and volvulus in adult life. Int J Surg Case Rep. Jan. 2014;5(5):259–61. 10.1016/j.ijscr.2014.02.013 . Sooltan AR, Sor E. Acute Appendicitis for a Patient with Situs Inversus. AIJR Synop. May 2025;1(1):4–6. 10.21467/synopsis.1.1.2 . Additional Declarations No competing interests reported. Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. 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1","display":"","copyAsset":false,"role":"figure","size":77666,"visible":true,"origin":"","legend":"\u003cp\u003eAbdominal X-ray showed free air under diaphragm.\u003c/p\u003e","description":"","filename":"floatimage1.png","url":"https://assets-eu.researchsquare.com/files/rs-7631775/v1/5c4e2397cb532db43116b652.png"},{"id":93337913,"identity":"8488d4da-8925-48d4-8c62-58e8c1d1e994","added_by":"auto","created_at":"2025-10-12 14:13:50","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":50887,"visible":true,"origin":"","legend":"\u003cp\u003eAbdominal CT- scan revealed cecum and appendix located in the left lower quadrant, sigmoid colon positioned in the right iliac fossa.\u003c/p\u003e","description":"","filename":"floatimage2.png","url":"https://assets-eu.researchsquare.com/files/rs-7631775/v1/7d73bdfaf7038e18b15eed8f.png"},{"id":93336439,"identity":"bd8c6bf7-23c1-443e-8871-85e51a83f2c6","added_by":"auto","created_at":"2025-10-12 14:05:50","extension":"png","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":34537,"visible":true,"origin":"","legend":"\u003cp\u003eAbdominal CT- Scan showing a signs of free intraperitoneal air and fluid, with inflamed, perforated appendix at midshaft, surrounded by fecal contamination.\u003c/p\u003e","description":"","filename":"floatimage3.png","url":"https://assets-eu.researchsquare.com/files/rs-7631775/v1/d71aa4b067d5186313439b5b.png"},{"id":93337915,"identity":"080692c5-486b-46cb-9179-7d9bfd4cfdf4","added_by":"auto","created_at":"2025-10-12 14:13:50","extension":"png","order_by":4,"title":"Figure 4","display":"","copyAsset":false,"role":"figure","size":543438,"visible":true,"origin":"","legend":"\u003cp\u003eLaparatomy of abdominal cavity showing a partial situs inversus in which transverse colon and sigmoid colon displaced to the right, small bowel and cecum to the left.\u003c/p\u003e","description":"","filename":"floatimage4.png","url":"https://assets-eu.researchsquare.com/files/rs-7631775/v1/7c4b36d5b2caee88a6f460ce.png"},{"id":93336450,"identity":"e9d79392-8002-4e15-b335-d0aeae75a346","added_by":"auto","created_at":"2025-10-12 14:05:50","extension":"png","order_by":5,"title":"Figure 5","display":"","copyAsset":false,"role":"figure","size":607941,"visible":true,"origin":"","legend":"\u003cp\u003eShowing the perforation at the midshaft of the appendix with fecal contamination.\u003c/p\u003e","description":"","filename":"floatimage5.png","url":"https://assets-eu.researchsquare.com/files/rs-7631775/v1/16ebfaa74e5f8d4ac3840926.png"},{"id":93337916,"identity":"a011f39d-bf87-4e5c-9797-e1d743659d7c","added_by":"auto","created_at":"2025-10-12 14:13:50","extension":"png","order_by":6,"title":"Figure 6","display":"","copyAsset":false,"role":"figure","size":530444,"visible":true,"origin":"","legend":"\u003cp\u003eShowing the generalized purulent peritonitis.\u003c/p\u003e","description":"","filename":"floatimage6.png","url":"https://assets-eu.researchsquare.com/files/rs-7631775/v1/238c2644785cc4d7bd0ffe35.png"},{"id":107526707,"identity":"d6e85513-0e20-462b-9011-b2e78a8ea02a","added_by":"auto","created_at":"2026-04-22 09:43:54","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1957620,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-7631775/v1/f26002e1-e629-45e2-9b45-9adf5f980022.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Rare Case Report: Partial Situs Inversus with Intestinal Malrotation and Perforated Appendicitis with Generalized Peritonitis in a 65-Year-Old Male","fulltext":[{"header":"Introduction","content":"\u003cp\u003eAppendicitis usually manifests acutely within 24 hours and is defined by inflammation of the vermiform appendix [1]. Appendicitis remains one of the most common surgical emergencies faced by the surgeon in the surgical department [2]. The typical presentation of acute appendicitis is characterized by fever, anorexia, and peritoneal response upon examination, along with periumbilical pain spreading to the right lower quadrant of the abdomen [3]. However, unusual clinical manifestations have been documented, including back pain, lower abdominal quadrant discomfort, particularly in situs inverus, left flank or left hypochondrium pain, and intestinal malrotation [4]. Midgut malrotation (MM) and situs inversus (SI) are rare anatomic abnormalities that make diagnosing and treating acute abdominal pain more difficult [5] [6].\u0026nbsp;Situs inversus is a rare congenital condition that produces a \"mirror image\" by transposing the abdominal organs, viscera, and vasculature with respect to the sagittal direction. \u0026nbsp;While partial situs inversus only affects one or more organs, totalis situs inversus is defined as involving dextrocardia\u0026nbsp;[7]\u0026nbsp;[8].\u0026nbsp;A fetal abnormality known as midgut malrotation arises when the superior mesenteric artery's axis fails to rotate, and this is followed by retroperitoneal fixation. \u0026nbsp;With an approximate incidence of one in 500 live births, it is a rare disorder\u0026nbsp;[3]\u0026nbsp;[5]\u0026nbsp;. According to estimates, 85% of cases manifest during the first two weeks of life\u0026nbsp;[5]. Acute appendicitis is still the most common reason for gastrointestinal surgical emergency procedures, and it is typically easy to diagnose. \u0026nbsp;When the appendix is malpositioned, diagnostic ambiguity may arise because acute appendicitis does not always appear in the same way. \u0026nbsp;Located 2.5 cm behind the ileocecal valve on the posterio-medial part of the cecum, the appendix is a vestigial organ\u0026nbsp;[9]. \u0026nbsp; The anatomical position of this organ is the only one that varies across the body. The retrocecal, pelvic, subcecal, preileal, and postileal are among the different placements; less frequently observed are subhepatic, mesoceliac, intrahernial (femoral or inguinal), and left-sided\u0026nbsp;[6]\u0026nbsp;[2]. The appendix is a blind-ending structure anatomically\u0026nbsp;[9]. In cases of extreme severity, a closed-loop blockage of its lumen causes inflammation and transmural necrosis, which ultimately result in peritonitis and the perforation and release of the luminal contents (pus and fecaliths)\u0026nbsp;[10].\u003c/p\u003e\n\u003cp\u003eAcute appendix perforation is a dangerous side effect of appendicitis that is linked to higher rates of morbidity and death. \u0026nbsp;Extremes of age, male gender, pregnancy, immunosuppression, coexisting medical conditions, and previous abdominal procedures are risk factors for perforated appendicitis [8]. While it varies, the incidence of macroscopic appendiceal perforation in large series is approximately 20–30%. \u0026nbsp;Generalized peritonitis or localized walled-off accumulations of pus (appendix abscess) are the next steps after an appendiceal perforation. \u0026nbsp; Approximately 20% of children with acute appendicitis have a fecolith. Pseudomonas aeruginosa, Peptostreptococcus species, Fusobacteria, Escherichia coli, and Bacteroides fragilis are among the common bacterial isolates seen in perforated appendicitis [9] [11]. Adults rarely exhibit situs inversus, particularly those who have no complaints. Situs inversus is diagnosed incidentally with other entities such as appendicitis or cholecystitis [12] . The incidence of situs inversus is 0.001% to 0.01% of the general population [12]. Therefore, it is challenging to determine an exact incidence because this problem may go undiagnosed and asymptomatic until it is found during adult tests or surgery for other gastrointestinal pathologies. Due to intestinal malrotation's rarity, clinical suspicion of the condition decreases with age. We report a case of partial situs inversus with intestinal malrotation and perforated appendicitis with generalized peritonitis in 65-year-old male.\u003c/p\u003e"},{"header":"Case Presentation","content":"\u003cp\u003eA 65-year-old male patient presented to the emergency department of Ambo University Referral Hospital, Ambo, Ethiopia with a severe, diffuse abdominal pain of 3 days' duration, associated with fever, nausea, and abdominal distension. The pain initially began in the left lower quadrant and progressively worsened to involve the entire abdomen. The patient denied any history of past abdominal surgery, medical illnesses, or injuries to the abdomen. \u0026nbsp;He reported as drinker in social situations, but he had no prior medical history of asthma, diabetes, hypertension, or similar conditions.\u003c/p\u003e\n\u003ch3\u003eClinical findings and Physical examinations\u003c/h3\u003e\n\u003cp\u003eDuring physical examination the patient\u0026rsquo;s vital signs were: temperature of 38.8\u0026deg;C, pulse rate of 112 beats per minutes, Blood Pressure of 95/60 mmHg and a respiratory rate of 20 breadths per minute.\u003c/p\u003e\u003cp\u003eAbdominal examination revealed: there was abdominal distension, rebound tenderness and guarding across all quadrants, hypoactive bowel sounds and the digital rectal examination revealed that there was empty rectum; tenderness on right side of pelvis.\u003c/p\u003e\n\u003ch3\u003eLaboratory and Radiological Investigations\u003c/h3\u003e\n\u003cp\u003eLaboratory tests showed leukocytosis with neutrophil predominance. Abdominal X-ray and abdominal CT- scan with Contrast were ordered. Abdominal X-ray showed free air under diaphragm and abdominal CT- scan revealed cecum and appendix located in the left lower quadrant, sigmoid colon positioned in the right iliac fossa, duodenojejunal junction on the left side but not crossing midline, and signs of free intraperitoneal air and fluid, with inflamed, perforated appendix at midshaft, surrounded by fecal contamination. Finally the patient was diagnosed with partial situs inversus with intestinal malrotation complicated by perforated midshaft appendicitis and generalized peritonitis.\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e\u003ch2\u003eIntraoperative Findings\u003c/h2\u003e\u003cp\u003eExploratory Laparatomy of abdominal cavity was done with a minimally disruptive approach. Then the peritoneal cavity was explored showing a partial situs inversus in which transverse colon and sigmoid colon displaced to the right, small bowel and cecum to the left. Regarding the malrotation, the bowel was unfixed with narrow mesenteric base, perforation at the midshaft of the appendix with fecal contamination, and generalized purulent peritonitis. Ladd\u0026rsquo;s procedure was performed to correct malrotation, and appendectomy was done with peritoneal lavage and drainage.\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003c/div\u003e"},{"header":"Discussion","content":"\u003cp\u003eThis is a rare and complex case of partial situs inversus and intestinal malrotation in an elderly male, presenting for the first time with perforated appendicitis and diffuse peritonitis. This case is particularly unusual due to: the appendix being located in the left lower quadrant, perforation at the midshaft, rather than the tip or base and coexistence of partial situs inversus and malrotation, both congenital and rarely symptomatic in adulthood.\u003c/p\u003e\u003cp\u003eSitus inversus is a congenital condition involving reversal of visceral organ positioning; partial situs inversus refers to an incomplete mirror-image anatomy [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eIntestinal malrotation, usually diagnosed in infancy, which results from incomplete rotation of the midgut during embryogenesis. Adult presentation is rare and often incidental or complicated by obstruction or volvulus [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e]. Appendicitis in malrotation and situs inversus is notoriously difficult to diagnose preoperatively due to atypical pain localization, often delaying diagnosis and increasing the risk of complications such as perforation and peritonitis [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e].\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eThis is a rare and life-threatening case of perforated midshaft appendicitis with generalized peritonitis in a patient with partial situs inversus and intestinal malrotation. It emphasizes the importance of considering congenital anatomical variants in adults with atypical abdominal pain, and the need for early imaging to guide timely surgical intervention.\u003c/p\u003e"},{"header":"Declarations","content":"\u003ch3\u003eDisclosure of ethics statement\u003c/h3\u003e\n\u003cp\u003e The patient gave written informed consent for this case report and any related photos to be published. In order to undertake all procedures in compliance with applicable rules and legislation to protect human subjects and their data, a formal informed consent form was read and signed. All patient information was kept private. Participants' names and other personal information were kept private.\u003c/p\u003e\n\u003ch3\u003eConflict Interest\u003c/h3\u003e\n\u003cp\u003eThe authors declared no conflict of interest.\u003c/p\u003e\u003ch2\u003eFunding\u003c/h2\u003e\u003cp\u003eThe authors did not receive any specific funding for this work.\u003c/p\u003e\u003ch2\u003eAuthor Contribution\u003c/h2\u003e\u003cp\u003eN.T. wrote the main manuscript and E.M, S.A,T.B, K.M and I.G done the surgical procedure and read the radiological findingsK.N reviewed the main manuscript\u003c/p\u003e\u003ch2\u003eAcknowledgement\u003c/h2\u003e\u003cp\u003eWe express a debt of gratitude to the patient and all those involved in this case report for its publication\u003c/p\u003e\u003ch2\u003eData Availability\u003c/h2\u003e\u003cp\u003eThe authors did not receive any specific funding for this work.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eLotfollahzadeh S, Lopez RA, Deppen JG. 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Jan. 2014;5(5):259\u0026ndash;61. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1016/j.ijscr.2014.02.013\u003c/span\u003e\u003cspan address=\"10.1016/j.ijscr.2014.02.013\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eSooltan AR, Sor E. Acute Appendicitis for a Patient with Situs Inversus. AIJR Synop. May 2025;1(1):4\u0026ndash;6. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.21467/synopsis.1.1.2\u003c/span\u003e\u003cspan address=\"10.21467/synopsis.1.1.2\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"","lastPublishedDoi":"10.21203/rs.3.rs-7631775/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-7631775/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003eA male patient, age 65, arrived at the emergency room of Ambo University Referral Hospital in Ambo, Ethiopia, complaining of severe, diffuse abdominal discomfort that had persisted for three days. The patient also had fever, nausea, and distension in his abdomen. After starting in the lower left quadrant, the discomfort gradually spread throughout the entire abdomen. Intestinal malrotation, usually diagnosed in infancy, which results from incomplete rotation of the midgut during embryogenesis. Adult presentation is rare and often incidental or complicated by obstruction or volvulus. It emphasizes the importance of considering congenital anatomical variants in adults with atypical abdominal pain, and the need for early imaging to guide timely surgical intervention.\u003c/p\u003e","manuscriptTitle":"Rare Case Report: Partial Situs Inversus with Intestinal Malrotation and Perforated Appendicitis with Generalized Peritonitis in a 65-Year-Old Male","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-10-12 14:05:45","doi":"10.21203/rs.3.rs-7631775/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"97d6c1f2-aa04-461e-8761-30d044611bc1","owner":[],"postedDate":"October 12th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2026-04-22T09:43:19+00:00","versionOfRecord":[],"versionCreatedAt":"2025-10-12 14:05:45","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-7631775","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-7631775","identity":"rs-7631775","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}