Valentino's syndrome

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Valentino's syndrome is pain presenting in the right lower quadrant of the abdomen caused by a duodenal ulcer with perforation through the retroperitoneum. [1]

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It is named after Rudolph Valentino, an Italian actor, who presented with right lower quadrant pain in New York, which turned out to be a perforated peptic ulcer. He subsequently died from an infection and organ dysfunction [2] in spite of surgery to repair the perforation. [3] Due to his popularity, his case received much attention at the time and is still considered a rare medical condition.

However, the degree of peritoneal findings is strongly influenced by a number of factors, including the size of perforation, amount of bacterial and gastric contents contaminating the abdominal cavity, time between perforation and presentation, and spontaneous sealing of perforation.

Signs and symptoms

Patients with perforated Valentino's syndrome usually present with a sudden onset of severe, sharp abdominal pain in the right lower quadrant (RLQ), that is similar to acute appendicitis. [4] Most patients describe generalized pain; a few present with severe epigastric pain, located in the upper abdominal area. As even slight movement can tremendously worsen their pain, these patients assume a fetal position. These patients may also demonstrate signs and symptoms of septic shock, such as tachycardia (increased heart rate), hypotension (low blood pressure), and anuria (when no urine is produced from the kidneys). [2] Not surprisingly, these indicators of shock may be absent in elderly, immunocompromised patients or in those with diabetes. Patients also experience nausea, vomiting, decreased appetite, and sweating.

Cause

The cause for Valentino's syndrome is due to a perforated ulcer located in the duodenum. This occurs when ulcers that have gone untreated for long periods of time, and as a result has burned through the stomach wall. Risk factors for a perforated ulcers include bacterial infection, such as H. pylori , and routine use of nonsteroidal anti-inflammatory drugs. [2] The right lower quadrant pain is caused by peritonitis from exposure to gastrointestinal fluids draining down from the perforation in the right upper quadrant. [3] [5] The exact incidence of Valentino's syndrome is unknown. [6]

Pathophysiology

Peptic ulcers are sores or defects that arise from tissue death, that develop in the mucosal lining of the stomach or duodenum. [7] When a peptic ulcer bursts, the gastrointestinal or duodenal fluid leaks through it and pools in the right paracolic gutter [2] which leads to inflammation of the peritoneum resulting in symptoms right lower quadrant of abdominal pain. [6] Patients also develop pneumoretroperitoneum, which is air in the retroperitoneum, caused by intraperitoneal perforation in the duodenum. [7] Untreated peptic ulcers can often lead to greater complications such as hemorrhage, obstruction, and cancer. [2]

Diagnosis

Diagnosing Valentino's syndrome could be very difficult because of the condition's many similarities to appendicitis. However, a medical history of ulcers and use of NSAIDs could be an indicator.

When patients present with right lower quadrant pain their vitals, such as blood pressure, pulse, oxygen saturation, and temperature, are monitored. A complete blood count (CBC) is done to determine the number of white blood cells present in the patient's blood and test for leukocytosis, a condition in which the white blood cells are above the normal levels.[ citation needed ]

Abdominal examination usually discloses generalized tenderness, rebound tenderness in the right iliac fossa, [7] guarding, and rigidity. A physical examination that is positive for abdominal pain categorized as McBurney's point tenderness, Blumberg's sign, Rovsing's sign, Dunphy's sign and psoas sign, could all indicate acute appendicitis and lead to misdiagnosis.[ citation needed ] However, these physical examination findings are also present in Valentino's Syndrome.

In order to diagnose Valentino's syndrome, a CT or ultrasound may be performed, which would reveal a ruptured peptic ulcer and free fluid surrounding the area of the appendix. [6] Diagnosis through laparoscopy can also be done to distinguish between acute appendicitis and Valentino's syndrome.[ citation needed ]

Since there has been very few cases of Valentino's syndrome recorded to this day, [4] most studies on this condition include observations of the patient from onset to recovery and on site medical decision making.[ citation needed ]

Treatment

Treatment would include emergency surgery in order to repair the ruptured peptic ulcer. [6] This is done by irrigation with saline solution, draining excess fluid, and surgically closing the perforation. Patients are then observed for a certain period of time before being discharged when no post-operative complications arise and are advised to follow up with their physician for post-operative examination. [7]

Related Research Articles

<span class="mw-page-title-main">Peptic ulcer disease</span> Ulcer of an area of the gastrointestinal tract

Peptic ulcer disease (PUD) is a break in the inner lining of the stomach, the first part of the small intestine, or sometimes the lower esophagus. An ulcer in the stomach is called a gastric ulcer, while one in the first part of the intestines is a duodenal ulcer. The most common symptoms of a duodenal ulcer are waking at night with upper abdominal pain, and upper abdominal pain that improves with eating. With a gastric ulcer, the pain may worsen with eating. The pain is often described as a burning or dull ache. Other symptoms include belching, vomiting, weight loss, or poor appetite. About a third of older people have no symptoms. Complications may include bleeding, perforation, and blockage of the stomach. Bleeding occurs in as many as 15% of cases.

<span class="mw-page-title-main">Appendicitis</span> Inflammation of the appendix

Appendicitis is inflammation of the appendix. Symptoms commonly include right lower abdominal pain, nausea, vomiting, and decreased appetite. However, approximately 40% of people do not have these typical symptoms. Severe complications of a ruptured appendix include widespread, painful inflammation of the inner lining of the abdominal wall and sepsis.

<span class="mw-page-title-main">Peritonitis</span> Medical condition

Peritonitis is inflammation of the localized or generalized peritoneum, the lining of the inner wall of the abdomen and cover of the abdominal organs. Symptoms may include severe pain, swelling of the abdomen, fever, or weight loss. One part or the entire abdomen may be tender. Complications may include shock and acute respiratory distress syndrome.

<span class="mw-page-title-main">Cholecystitis</span> Inflammation of the gallbladder

Cholecystitis is inflammation of the gallbladder. Symptoms include right upper abdominal pain, pain in the right shoulder, nausea, vomiting, and occasionally fever. Often gallbladder attacks precede acute cholecystitis. The pain lasts longer in cholecystitis than in a typical gallbladder attack. Without appropriate treatment, recurrent episodes of cholecystitis are common. Complications of acute cholecystitis include gallstone pancreatitis, common bile duct stones, or inflammation of the common bile duct.

<span class="mw-page-title-main">Abdominal pain</span> Stomach aches

Abdominal pain, also known as a stomach ache, is a symptom associated with both cancer and serious medical issues.

<span class="mw-page-title-main">Meckel's diverticulum</span> Medical condition

A Meckel's diverticulum, a true congenital diverticulum, is a slight bulge in the small intestine present at birth and a vestigial remnant of the omphalomesenteric duct. It is the most common malformation of the gastrointestinal tract and is present in approximately 2% of the population, with males more frequently experiencing symptoms.

<span class="mw-page-title-main">Gastrointestinal disease</span> Medical condition

Gastrointestinal diseases refer to diseases involving the gastrointestinal tract, namely the esophagus, stomach, small intestine, large intestine and rectum, and the accessory organs of digestion, the liver, gallbladder, and pancreas.

<span class="mw-page-title-main">Rovsing's sign</span> Medical condition

Rovsing's sign, named after the Danish surgeon Niels Thorkild Rovsing (1862–1927), is a sign of appendicitis. If palpation of the left lower quadrant of a person's abdomen increases the pain felt in the right lower quadrant, the patient is said to have a positive Rovsing's sign and may have appendicitis. The phenomenon was first described by Swedish surgeon Emil Samuel Perman (1856-1945) writing in the journal Hygiea in 1904.

<span class="mw-page-title-main">Gastrointestinal perforation</span> Medical condition

Gastrointestinal perforation, also known as ruptured bowel, is a hole in the wall of part of the gastrointestinal tract. The gastrointestinal tract includes the esophagus, stomach, small intestine, and large intestine. Symptoms include severe abdominal pain and tenderness. When the hole is in the stomach or early part of the small intestine, the onset of pain is typically sudden while with a hole in the large intestine onset may be more gradual. The pain is usually constant in nature. Sepsis, with an increased heart rate, increased breathing rate, fever, and confusion may occur.

<span class="mw-page-title-main">Esophageal rupture</span> Medical condition

Esophageal rupture is a rupture of the esophageal wall. Iatrogenic causes account for approximately 56% of esophageal perforations, usually due to medical instrumentation such as an endoscopy or paraesophageal surgery. In contrast, the term Boerhaave syndrome is reserved for the 10% of esophageal perforations which occur due to vomiting.

<span class="mw-page-title-main">Pneumoperitoneum</span> Medical condition

Pneumoperitoneum is pneumatosis in the peritoneal cavity, a potential space within the abdominal cavity. The most common cause is a perforated abdominal organ, generally from a perforated peptic ulcer, although any part of the bowel may perforate from a benign ulcer, tumor or abdominal trauma. A perforated appendix seldom causes a pneumoperitoneum.

An acute abdomen refers to a sudden, severe abdominal pain. It is in many cases a medical emergency, requiring urgent and specific diagnosis. Several causes need immediate surgical treatment.

<span class="mw-page-title-main">Bowel resection</span> Surgical procedure in which a part of an intestine is removed

A bowel resection or enterectomy is a surgical procedure in which a part of an intestine (bowel) is removed, from either the small intestine or large intestine. Often the word enterectomy is reserved for the sense of small bowel resection, in distinction from colectomy, which covers the sense of large bowel resection. Bowel resection may be performed to treat gastrointestinal cancer, bowel ischemia, necrosis, or obstruction due to scar tissue, volvulus, and hernias. Some patients require ileostomy or colostomy after this procedure as alternative means of excretion. Complications of the procedure may include anastomotic leak or dehiscence, hernias, or adhesions causing partial or complete bowel obstruction. Depending on which part and how much of the intestines are removed, there may be digestive and metabolic challenges afterward, such as short bowel syndrome.

<span class="mw-page-title-main">Gastric outlet obstruction</span> Medical condition

Gastric outlet obstruction (GOO) is a medical condition where there is an obstruction at the level of the pylorus, which is the outlet of the stomach. Individuals with gastric outlet obstruction will often have recurrent vomiting of food that has accumulated in the stomach, but which cannot pass into the small intestine due to the obstruction. The stomach often dilates to accommodate food intake and secretions. Causes of gastric outlet obstruction include both benign causes, as well as malignant causes, such as gastric cancer.

Stercoral ulcer is an ulcer of the colon due to pressure and irritation resulting from severe, prolonged constipation due to a large bowel obstruction, damage to the autonomic nervous system, or stercoral colitis. It is most commonly located in the sigmoid colon and rectum. Prolonged constipation leads to production of fecaliths, leading to possible progression into a fecaloma. These hard lumps irritate the rectum and lead to the formation of these ulcers. It results in fresh bleeding per rectum. These ulcers may be seen on imaging, such as a CT scan but are more commonly identified using endoscopy, usually a colonoscopy. Treatment modalities can include both surgical and non-surgical techniques.

<span class="mw-page-title-main">Epiploic appendagitis</span> Medical condition

Epiploic appendagitis (EA) is an uncommon, benign, self-limiting inflammatory process of the epiploic appendices. Other, older terms for the process include appendicitis epiploica and appendagitis, but these terms are used less now in order to avoid confusion with acute appendicitis.

<span class="mw-page-title-main">Perforated ulcer</span> Medical condition

A perforated ulcer is a condition in which an untreated ulcer has burned through the mucosal wall in a segment of the gastrointestinal tract allowing gastric contents to leak into the abdominal cavity.

Abdominal guarding is the tensing of the abdominal wall muscles to guard inflamed organs within the abdomen from the pain of pressure upon them. The tensing is detected when the abdominal wall is pressed. Abdominal guarding is also known as 'défense musculaire'.

Markle's sign, or jar tenderness, is a clinical sign in which pain in the right lower quadrant of the abdomen is elicited by the heel-drop test.

<span class="mw-page-title-main">Quadrants and regions of abdomen</span> Anatomical subdivision scheme

The human abdomen is divided into quadrants and regions by anatomists and physicians for the purposes of study, diagnosis, and treatment. The division into four quadrants allows the localisation of pain and tenderness, scars, lumps, and other items of interest, narrowing in on which organs and tissues may be involved. The quadrants are referred to as the left lower quadrant, left upper quadrant, right upper quadrant and right lower quadrant. These terms are not used in comparative anatomy, since most other animals do not stand erect.

References

  1. ↑ DeVirgilio C, Grigorian A (2017). Review of Surgery for ABSITE and Boards E-Book. Elsevier Health Sciences. p. 113. ISBN   9780323416801.
  2. 1 2 3 4 5 Amann CJ, Austin AL, Rudinsky SL (March 2017). "Valentino's Syndrome: A Life-Threatening Mimic of Acute Appendicitis". Clinical Practice and Cases in Emergency Medicine. 1 (1): 44–46. doi:10.5811/cpcem.2016.11.32571. PMC   5965439 . PMID   29849430.
  3. 1 2 Bhat MS (2016). SRB's Manual of Surgery. JP Medical Ltd. p. 831. ISBN   9789351524168.
  4. 1 2 Acute Appendicitis: New Insights for the Healthcare Professional (2013 ed.). ScholarlyEditions. 2013. p. 36. ISBN   9781481650380.
  5. ↑ Williams N, O'Connell PR (2013). Bailey & Love's Short Practice of Surgery 26E. CRC Press. p. 971. ISBN   9781444165029.
  6. 1 2 3 4 Sharma R. "Valentino syndrome | Radiology Reference Article". Radiopaedia S. Retrieved 2019-10-13.
  7. 1 2 3 4 Mahajan PS, Abdalla MF, Purayil NK (2014-05-27). "First Report of Preoperative Imaging Diagnosis of a Surgically Confirmed Case of Valentino's Syndrome". Journal of Clinical Imaging Science. 4: 28. doi:10.4103/2156-7514.133263. PMC   4078456 . PMID   24991479.
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