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 Table of Contents  
CASE REPORT
Year : 2017  |  Volume : 2  |  Issue : 4  |  Page : 106-108

Valentino's syndrome: An unusual presentation of a perforated peptic ulcer


1 Faculty of Medicine, University of Pavia, Pavia, Italy
2 Department of Histopathology, Broomfield Hospital, Chelmsford, England, UK
3 Department of Surgery, Sant'Antonio Abate Hospital, Gallarate; University of Insubria, Varese, Italy
4 Department of Surgery, Sant'Antonio Abate Hospital, Gallarate, Italy

Date of Submission04-Jul-2017
Date of Acceptance15-Oct-2017
Date of Web Publication28-Dec-2017

Correspondence Address:
Francesco Pata
Department of Surgery, Sant'Antonio Abate Hospital, via E. Pastori 4, Gallarate, 21013
Italy
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ts.ts_16_17

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  Abstract 

Valentino's syndrome occurs when digestive fluids tend to settle in the right iliac fossa through a perforated gastric or duodenal ulcer, causing peritonitis and clinically mimicking acute appendicitis. Herein, we present the case of a 32-year-old male who was admitted to the emergency department with signs and symptoms suggestive of acute appendicitis. During laparoscopic appendectomy, inspection of the peritoneal cavity revealed an anterior, perforated duodenal ulcer, which was treated with a patch repair. The patient's recovery was uneventful, and a gastrointestinal endoscopy at his 6-week follow-up showed complete healing of the ulcer. This case highlights that Valentino's syndrome should be considered in the differential diagnosis of any patient who has an abdominal examination consistent with acute appendicitis.

Keywords: Acute appendicitis, duodenal ulcer perforation, laparoscopy, Valentino's syndrome


How to cite this article:
Sgro A, Petkar M, Benevento A, Pata F. Valentino's syndrome: An unusual presentation of a perforated peptic ulcer. Transl Surg 2017;2:106-8

How to cite this URL:
Sgro A, Petkar M, Benevento A, Pata F. Valentino's syndrome: An unusual presentation of a perforated peptic ulcer. Transl Surg [serial online] 2017 [cited 2018 Apr 25];2:106-8. Available from: http://www.translsurg.com/text.asp?2017/2/4/106/221875


  Introduction Top


Right iliac fossa pain is a common presenting symptom in the emergency department and can result from a wide spectrum of conditions. The initial consideration in most patients is acute appendicitis; however, several other conditions may present with similar clinical and laboratory features, and therefore present a diagnostic challenge to the clinician.[1],[2] One such condition, although a rare event, is Valentino's syndrome. Valentino's syndrome is caused by perforation of a peptic or duodenal ulcer, leading to right lower quadrant abdominal pain, thereby mimicking acute appendicitis.[3],[4],[5],[6] It can be life threatening if not diagnosed and promptly treated. We present the case of a 32-year-old male admitted to our department with symptoms and signs suggestive of acute appendicitis but intraoperatively diagnosed with Valentino's syndrome.


  Case Report Top


A 32-year-old male presented to the Emergency Department of Sant'Antonio Abate Hospital (Gallarate, Italy) with a sudden onset of lower abdominal pain localized to the right iliac fossa. He reported no diarrhea, weight loss, or back pain, and denied being on any medication. His weight was 50 kg and body mass index was 25 kg/m 2. The patient had no smoking history and his family history was unremarkable. The remainder of the physical examination revealed fever (38°C) and right lower abdominal tenderness with guarding. Laboratory data revealed a mild leukocytosis (white blood cell count of 16,900/uL) and slightly raised inflammatory markers (C-reactive protein: 1.1 mg/dL). Liver function tests were normal and urinalysis was not performed. A small amount of free fluid in the right iliac fossa was noted by ultrasound. Taking into consideration the classical clinical symptoms and signs, as well as raised inflammatory markers, a clinical diagnosis of acute appendicitis was made. The patient was admitted to the General Surgery Department and he underwent a laparoscopic appendectomy. Laparoscopy found a vermiform, hyperemic appendix surrounded by turbid fluid within the right iliac fossa. After appendectomy, further laparoscopic evaluation of the peritoneal cavity revealed a turbid pericholecystic fluid and inflammation. Three additional ports were placed in the epigastrium, right hypochondrium, and right flank to provide a good exposure of the new operative field [Figure 1]. After mobilization of the greater omentum, an anterior, perforated duodenal ulcer was discovered [Figure 2], pointing to the diagnosis of Valentino's syndrome. The ulcer was repaired by mobilizing the greater omentum and using it to patch the ulcer (Graham patch). Two drains without suction were placed, one in the subhepatic region and one in the pelvis, and the incisions were closed. The patient was commenced on intravenous proton pump inhibitors. Helicobacter serology subsequently came back negative. The patient's recovery was uneventful and he was discharged on proton pump inhibitors. An outpatient upper gastrointestinal endoscopy performed 6 weeks postoperatively showed complete healing of the ulcer.
Figure 1: Postoperative image, with red circles indicating the position of additional ports necessary to perform the ulcer repair during laparoscopy

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Figure 2: Intraoperative view of the perforated anterior duodenal ulcer (arrow) discovered during laparoscopy

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  Discussion Top


Valentino's syndrome occurs when digestive fluids tend to settle in the right iliac fossa following gastric or duodenal ulcer perforation, causing peritonitis and clinically mimicking acute appendicitis.[3],[5],[6] The syndrome takes its name from the 1920's silent film star Rudolph Valentino. In 1926, at the age of 31, he presented with pain in the right lower abdomen and was diagnosed and treated as a case of acute appendicitis at New York Polytechnic Hospital. After the appendectomy, however, he developed acute peritonitis, multiorgan failure, and later died. The autopsy revealed a perforated gastric ulcer as his cause of death.[4]

Perforation of an anterior peptic ulcer allows free leakage of duodenal and gastric contents into the peritoneal cavity. These contents will often collect in the right iliac fossa and the patient may experience poorly localized pain in the early course of the disease. However, if medical attention is not sought promptly, localized pain to the right lower quadrant may develop, mimicking acute appendicitis so closely that the diagnosis of anterior, perforated duodenal ulcer is often made intraoperatively due to surgical exploration and without imaging.[3] Initial imaging, other than CT, may demonstrate free fluid around a normal appendix on ultrasound, as in this case, and free air around the kidney or “veiled kidney sign” on abdominal radiographs, especially in case of retroperitoneal perforation.[7]

Definitive treatment for a perforated duodenal ulcer is surgical and it entails the closure of perforation by Grahams patch or Cellan–Jones technique, even though conservative treatment with antibiotics, intravenous fluids, and H. Pylori triple therapy may be taken into account in selected circumstances.[7],[8] In case of a perforated gastric ulcer, an intraoperative biopsy should be performed to exclude malignancy.[9]

Valentino's syndrome has been mainly described in adults or elderly men, but occurrence in pediatric and pregnant patients has also been reported.[10],[11] Both cases were managed by open procedure.

In conclusion, the high morbidity and mortality associated with perforated peptic ulcers in this case emphasize the importance of considering Valentino's syndrome in the differential diagnosis of causes of right iliac fossa pain. Laparoscopic exploration can easily diagnose it, highlighting another advantage of laparoscopic appendectomy compared to open procedure in the surgical management of acute abdominal pain.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
  References Top

1.
Martin RF, Rossi RL. The acute abdomen. An overview and algorithms. Surg Clin North Am 1997;77 (6):1227-43.  Back to cited text no. 1
    
2.
Patel NB, Wenzke DR. Evaluating the patient with right lower quadrant pain. Radiol Clin North Am 2015;53 (6):1159-70.  Back to cited text no. 2
    
3.
Mahajan PS, Abdalla MF, Purayil NK. First report of preoperative imaging diagnosis of a surgically confirmed case of Valentino's syndrome. J Clin Imaging Sci 2014;4:28.  Back to cited text no. 3
    
4.
Wijegoonewardene SI, Stein J, Cooke D, Tien A. Valentino's syndrome a perforated peptic ulcer mimicking acute appendicitis. BMJ Case Rep 2012;28:1-3.  Back to cited text no. 4
    
5.
Ramírez-Ramírez MM, Villanueva-Saenz E. Valentino's syndrome. Perforated peptic ulcer with unusual clinical presentation. Rev Gastroenterol Mex 2016;81 (4):225-6.  Back to cited text no. 5
    
6.
Amann CJ, Austin AL, Rudinsky SL. Valentino's Syndrome: A life-threatening mimic of acute appendicitis. Clin Pract Cases Emerg Med 2017;1(1):44-6.  Back to cited text no. 6
    
7.
Wang HP, Su WC. Images in clinical medicine. Veiled right kidney sign in a patient with Valentino's syndrome. N Engl J Med 2006;354 (10):e9.  Back to cited text no. 7
    
8.
Prabhu V, Shivani A. An overview of history, pathogenesis and treatment of perforated peptic ulcer disease with evaluation of prognostic scoring in adults. Ann Med Health Sci Res 2014;4 (1):22-9.  Back to cited text no. 8
    
9.
Søreide K, Thorsen K, Harrison EM, Bingener J, Møller MH, Ohene-Yeboah M, Søreide JA. Perforated peptic ulcer. Lancet 2015;386 (10000):1288-98.  Back to cited text no. 9
    
10.
Hussain K, Mnir A, Wahla MS, Masood J. Valentino's syndrome: Perforated peptic ulcer mimicking acute appendicitis managed through Rutherford Morrison incision. J Coll Physicians Surg Pak 2016;26 (8):727-8.  Back to cited text no. 10
    
11.
Hsu CC, Liu YP, Lien WC, Lai TI, Wang HP. A pregnant woman presenting to the ED with Valentino's syndrome. Am J Emerg Med 2005;23 (2):217-8.  Back to cited text no. 11
    


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