Valentino syndrome

Valentino syndrome, oralso known as Valentino appendix, refers to a clinical syndrome of right lower quadrant or right iliac fossa pain secondary to a perforated peptic ulcer. It is an important differential diagnosis for acute appendicitis.

Epidemiology

Although thought to be a very rare manifestation of a perforated peptic ulcer ¹, the exact incidence of Valentino syndrome is unknown.

Clinical presentation

Clinical presentation mimics that of acute appendicitis, with signs and symptoms including ^1-3:

• localised pain, tenderness and guarding over the right lower quadrant
• nausea and vomiting
• fever

These clinical features are often much more prominent than those classic of peptic ulcer disease such as epigastric pain ^1-3.

Pathology

Valentino syndrome occurs due to gastrointestinal contents leaking through a perforated peptic ulcer tracking down the right paracolic gutter to the right iliac fossa ^1-5. This results in localised peritonism in this region and a mild chemical periappendicitis, accounting for the symptoms mimicking acute appendicitis ^1-5.

Radiographic features

Radiographic investigations, such as ultrasound or CT, may be performed with acute appendicitis being the working diagnosis, and often reveal a normal or mildly inflamed appendix ^1-5. However, patients may instead have radiographic features of a ruptured peptic ulcer, including subtle pneumoretroperitoneum, with accompanying free fluid and adjacent fat stranding demonstrable in the right paracolic gutter and around the appendix, reflecting the pathophysiological basis of the condition ^2,4,5. 

Treatment and prognosis

Treatment is a surgical emergency, with patients requiring repair of the rupture ^1-3. Post-operativelyPostoperatively, management should consider and address the cause of the peptic ulcer (e.g. Helicobacter pylori eradication therapy) ^1-3.

History and etymology

The syndrome is named after Rudolph Valentino (1895-1926), an American actor, who presented with clinical features of acute appendicitis and was managed with an appendicectomy, but later died from persisting complications of a ruptured peptic ulcer ^1,2.

Practical points

• in a patient presenting with worsening classic features of acute appendicitis, but has imaging showing a normal or near-normal appearing appendix, pay particular attention to subtle features of a ruptured peptic ulcer such as pneumoperitoneum and pneumoretroperitoneum