Valentino’s syndrome

Mădălina Șteţca
Student, “Iuliu Hațieganu” University of Medicine and Pharmacy, Cluj-Napoca
Introduction

Abstract. Valentino’s syndrome represents a clinical manifestation of duodenal perforation. Often,

the first symptom experienced by the patient is a sudden, sharp pain in the upper abdominal region. The
clinical presentation of the syndrome, however, bears a great degree of resemblance to that of appendici-
tis, a surgical emergency often regarded as the least life-threatening. To prevent any significant repercus-
sions that diagnostic errors can lead to, an early and precise differential diagnosis should be made. While
clinical evaluation represents the first step in reaching correct diagnosis, the more detailed examination
of the lesion is to be provided by the use of imaging exams. The most commonly preferred methods
are abdominal ultrasound, radiography and computed tomography (CT). These allow the examiner to
acknowledge the severity of the case and select the most appropriate treatment for the patient. Unless
Valentino’s syndrome is diagnosed early, diagnosis will be upgraded to severe sepsis, which eventually
might lead to death. Early diagnosis may spare the patient of this tragic consequence.
Keywords: perforation of duodenal ulcer, Valentino’s syndrome, acute appendicitis, peritoneal irrita-
tion, pneumoperitoneum, perforated ulcer.

quadrant, with appendicitis being the principal

Acute abdominal pain is a medical emergency surgical emergency. Until recently, clinical as-
requiring prompt assessment with which clinical sessment with minimal investigational support
doctors are constantly confronted. Its cause can was sufficient to perform an appendicectomy [2],
be attributed to a spectrum of conditions, rang- but for some time now, it has been proved that
ing from less severe to lethal. Various factors, such a number of pathologies share a similar clini-
as unreported drug intake or performed surger- cal presentation, thereby leading to misdiagno-
ies can obscure the clinical presentation of acute sis from the beginning. One such case is a rare
abdominal pain and prevent the clinician from clinical presentation of a perforated duodenal
reaching a diagnosis. Meticulous care is required ulcer, medically known as Valentino’s syndrome.
when considering all the possible diagnoses of
abdominal pain. Therefore, complete history tak- Pathophysiology
ing and physical evaluation are considered to be Although the exact etiology and nature of
the cornerstone of medical practice [1]. the disease process behind perforation remains
The cause of an acute abdomen may be very of- largely undetermined, the effect that the imbal-
ten missed, as it presents with certain symptoms ance between aggressive and defensive factors
that are never related to a specific pathology. has on the gastroduodenal mucosa is indisputable.
Pain is most often described in the right lower In this respect, the contribution of Helicobacter

22 23

Figure 1. Circulation of gastric fluids in the
peritoneal cavity directed by the attachments
of peritoneal ligaments
pylori (HP) and the chronic usage of nonsteroidal
anti-inflammatory drugs (NSAIDs) have been de-
bated [3].
A lack of self-care in terms of personal hy-
giene is correlated with a higher chance of con-
tracting HP, especially during childhood [4].
The improvement of current diagnostic tests al-
lows a more accurate diagnosis of HP infection,
treatment being now accessible to any physician.
As regards NSAIDs, these are a class of drugs
widely used for their anti-inflammatory and an-
algesic effects, which are indispensable in pain
management due to the combined role of the
cyclooxygenase (COX) pathway in the process
of inflammation and in the cellular recognition
of pain. It is widely accepted that withholding
medication in acute situations does not benefit
the diagnostic process and would only make the
patient uncooperative for distinct reasons [5].
The typical patient suffering from Valentino’s
syndrome is a male adult with a history of chron-
ic illness for which medication is administered
constantly. It bears noting that the most aggra-
vating symptom is pain in the upper abdominal
region, in relation to meals [3]. Nonetheless, cas-
es of Valentino’s syndrome have been observed
in children, but these are exceptionally rare [6,7].
24 25
Figure 2. The path taken by gastric fluids
in Valentino’s syndromes
Following ulcer perforation, digestive fluids
invade the peritoneal cavity, forming a passage to
compartments in different parts of the abdomen
(Figure 1). Digestive fluids are prone to ac­cu­mu­
late in the lower spaces due to the right paracolic
gutter (Figure 2). Clinically, this translates into
considerable pain perceived around the area [8].
Clinical features
Typical features of a duodenal ulcer include
abdominal pain, distention and dyspepsia. Once
the ulcer perforates, the gastroduodenal contents
invade the peritoneal cavity, generating a sharp
pain which does not subside regardless of the
administered medication [9].
The manifestation of duodenal ulcer perfora-
tion can be captured in three clinical phases:
▷▷ In the initial phase (up to 2 hours), the
pain is located in the epigastrium. In ad-
dition, a slight increase in body tempera-
ture and tachycardia can also be observed.
▷▷ An intermediate phase (between 2 to 12
hours) follows, in which the patient expe-
riences pain amelioration due to the dilu-
tion of duodenal contents by the exudate
from the peritoneum. Subsequently, the
accumulation of gastroduodenal contents
in the right lower quadrant (RLQ ) leads
to abdominal tenderness, guarding and
rigidity, which are signs of peritoneal ir-
ritation that can be clearly highlighted by
physical examination.
▷▷ In the third phase, (more than 12 hours)
severe signs of circulatory collapse, in-
cluding hypotension, hyperpyrexia and
abdominal distention can influence the
patient’s condition [3].
Other symptoms such as nausea or vomiting
have been described, but they are inconsistent.
Pain usually starts in the epigastrium, being
followed by an amelioration, and then it shifts
to the right iliac fossa and increases in intensity.
The association of the three clinical elements
consisting of sudden onset abdominal pain,
tachycardia and abdominal rigidity character-
izes duodenal ulcer perforation. In such cases, it
is very important to distinguish acute appendi-
citis from Valentino’s syndrome [9]. The clinical
picture is questionable, especially in elderly or
children, or in the obese [10]. Therefore, clinical
evaluation along with identification of the af-
fected organ and slowing of disease progression
are critical to treatment efficacy.
Laboratory and imaging investigations
in Valentino’s syndrome
Currently, there are no valid diagnostic labo-
ratory tests for the perforation of duodenal ul-
cer. Their usefulness lies solely in the evaluation
of the patient’s condition and exclusion of other
pathologies. Accordingly, it seems reasonable to
perform a complete blood count and a C-reac-
tive protein (CRP) measurement [10]. Markers
of inflammation are ought to be elevated, im-
plying that the process of inflammation unfolds.
Manifestations of a systemic inflammatory re-
sponse syndrome (SIRS), including leukocytocis,
increased body temperature and tachycardia,
can be reported. Also, an arterial blood gas test
is compulsory, as it excludes disorders of acid
base balance with metabolic acidosis found to be
the most frequently related [11].
Since hyperamylasemia is often associated
with acute pancreatitis, the serum amylase level
should be measured. This is routinely ordered in
cases of upper abdominal pain, especially in re-
lation to meals [12]. In this context, it has been
shown that elevated levels may also be associated
with perforated ulcer, especially if the perfora-
tion is produced shortly after meal, when the
pancreas releases large amounts of enzymes into
the circulation. It is considered to be a conse-
quence of massive absorption through the peri-
toneal surfaces, as a result of interruption of the
gastrointestinal barrier [13].
In addition to laboratory findings, another ac-
cessible examination is chest radiography that
reveals the pneumoperitoneum under the dia-
phragm.
Free air within the peritoneal cavity can also
be detected on an abdominal radiograph in dif-
ferent compartments, as follows:
▷▷ Around the bowel, marking the pres-
ence of air on both sides of the intestine
- Rigler sign (or double wall sign) [14];
▷▷ Involving the peritoneum, forming round
black areas - football sign [6];
▷▷ Outlining the falciform ligament - Silver
sign [15];
▷▷ Retroperitoneal, masking the right kidney
- veiled right kidney sign [16,17].
A major part in the process of diagnosing a
patient with right lower quadrant pain and sus-
pected acute appendicitis plays helical CT, which
is thoroughly recommended not only for its ac-
curacy in indicating the pneumoperitoneum, but
also for discarding other diagnoses. Some of its
benefits include offering an imaging technique
that is non-invasive, along with a better shape
and contour of the lesion. Its availability in all
medical facilities remains to be discussed [18].
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