Don’t get it twisted: POCUS diagnosis of acute appendicitis complicated by malrotation

Acute appendicitis is commonly diagnosed using clinical risk stratification tools, with point of care ultrasound (POCUS) playing a key role in timely and accurate diagnosis. We present a case of a 7-year-old female with right lower quadrant (RLQ) abdominal pain and vomiting, who was afebrile with a positive McBurney’s sign and voluntary guarding. Laboratory results showed leukocytosis with neutrophilia and negative inflammatory markers. POCUS revealed a blind-ending, non-compressible, aperistaltic tubular structure measuring 1.35 cm, but it could not be traced back to the cecum. Computed tomography (CT) imaging confirmed acute appendicitis and revealed an abnormal superior mesenteric vein (SMV) - superior mesenteric artery (SMA) relationship consistent with midgut malrotation without volvulus. This case highlights the importance of recognizing anatomic anomalies during POCUS to avoid misdiagnoses in atypical presentations of appendicitis.