Valentino's syndrome, named for the popular silent film actor Rudolph Valentino, was first described after he developed the signs and symptoms of appendicitis and underwent an appendectomy that failed to relieve his symptoms. He later developed overt peritonitis and developed multi-organ failure, to which he later succumbed. During his autopsy, it was discovered that he had been suffering from a perforated peptic ulcer [2].

By now, it has become a known fact that there are many conditions apart from VS that can present clinically similar to appendicitis and should be considered in the differential diagnosis before and during the operation [3].

After perforation of the duodenal ulcer, inflammatory fluid and alimentary tract contents seeped into the abdomen and trickled down the right colic gutter. As the purulent fluid remained in the abdomen, it caused peritonitis and referred pain from the same general area as the appendix, leading to the development of signs and symptoms mimicking acute appendicitis. Although the ulcer was not visualized endoscopically, vigilant gross examination of the duodenum led to identification of a pinhole perforation and diagnosis of Valentino's syndrome [2].

Peptic ulcers are caused by a combination of defensive factors (e.g., mucus-bicarbonate layer and prostaglandins) that protect the mucosa and aggravating factors (e.g., hydrochloric acid) that cause mucosa necrosis. Peptic ulcers can be caused by a number of factors, the most common of which is the overuse of NSAIDs, which inhibit COX and prostaglandin synthesis [3,5]. Furthermore, stress, irregular or unhealthy eating habits, H. pylori infections, and rare cases such as Crohn’s disease, Zollinger Elision syndrome, and Cushing’s syndrome or complications of malignancy, chemotherapy, or radiotherapy can all lead to peptic ulcer formation [4].

The presence of pneumoperitoneum is often formed by the intraperitoneal perforation of the stomach or first part of the duodenum, whereas pneumo-retroperitoneum (typical in the right kidney, ‘veiled right kidney sign’) is caused by a retroperitoneal perforation. The most reliable sign of appendicitis frequently manifests as epigastric or periumbilical pain that progressed to the RLQ [1].

On an erect chest X-ray, free peritoneal air may be identified as the air under the diaphragm. In ultrasonography or intraoperatively, a fluid collection is encircling the appendix as the gastric fluid courses through the right paracolic gutter into the right iliac fossa. In the context of acute appendicitis with epigastric pain, a CT scan is the suggested imaging investigation for the diagnosis of Valentino’s syndrome [5].