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Subhepatic appendicitis masquerading as acute cholecystitis: a lesson learnt! Subhepatic appendicitis can mimic other acute surgical abdominal conditions and can lead to a diagnostic dilemma. As surgery is the treatment of choice for appendicitis, establishing a proper diagnosis is of paramount importance especially to avoid dreadful complications like appendicular abscess, rupture and faecal peritonitis.1,2 This case illustrates the difficulty encountered in trying to diagnose acute appendicitis in patients whose appendix is mal-located during foetal development. We present this case of obstructive appendicitis, where in the diagnosis was established by radiological investigations and managed successfully. A 42-year-old man with diabetes presented with complaints of colicky right upper abdominal pain lasting for 2 days. He had three bouts of bilious vomiting and a low-grade fever. On examination, he was febrile (102°C) and tachycardic (110/min). Abdominal examination revealed a soft abdomen all over expect for tenderness, guarding and rigidity in the right hypochondrium. Murphy’s sign was positive with no mass palpable. There was no free fluid in the abdomen. Considering the symptoms and signs, a clinical diagnosis of acute cholecystitis was made. Blood investigations showed neutrophilia. An ultrasound (US) abdomen was done, which was inconclusive, but suspected acute calculous cholecystitis. A plain computed tomography (CT) scan of the abdomen was then done, which revealed an acutely inflamed tortuous subhepatic appendix with surrounding fat stranding and an obstructing faecolith (Fig. 1). Patient was subjected to an emergency laparoscopic appendectomy (LA) and the specimen was retrieved along with the faecolith (Fig. 2). Histopathology confirmed the diagnosis of acute appendicitis. Patient made a good post-operative recovery and on follow-up after 3 months is doing well. Acute appendicitis is one of the most common, easily diagnosed surgical emergencies and accounts for 1% of all surgical operations. Various appendicular positions that is retrocaecal (65.28%), pelvic (31%), subcaecal (2.26%), preileal (1%) and postileal (0.4%) have been described, but subhepatic position is a very rare position and is the result of a developmental anomaly (maldescent), where-in caecal descent towards the right iliac fossa is arrested and it lies in the subhepatic area.2,3 Palanivelu et al. reported an incidence of 0.08% subhepatic appendix among 7210 appendicitis in India.4 King in 1955 reported one of the early cases of subhepatic appendicitis.1 The diagnosis is usually missed preoperatively as it mimics acute cholecystitis and the presence of faecolith could be mistaken for gallstones on US abdomen, as in our patient.5 Abdominal CT is frequently required for diagnosis and has a high sensitivity (88– 100%) and specificity (92–98%).6 In situations where abdominal CT is inconclusive, clinical diagnosis of appendicitis remains doubtful and the patient remains clinically unwell, a diagnostic laparoscopy is © 2015 Royal Australasian College of Surgeons
Fig. 1. Plain computed tomography abdomen showing inflamed, tortuous subhepatic appendicitis with surrounding fat stranding (black arrow).
Fig. 2. Specimen of appendix with faecolith.
ANZ J Surg •• (2015) ••–••
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recommended.4 Appendicular abscess is the most reported complication in this site and rupture is a rare event, which could happen because of a delay in diagnosis.7 Obstructive appendicitis can be due to a faecolith as in our patient or parasitic infestation, Ascaris lumbricoides being the commonest.8 LA can be easily performed in these patients, resulting in shorter hospital stay and less post-operative complications. When difficult or when complications are present, open appendectomy should be performed.4 Recently laparoscopic submucosal appendectomy, a modified technique of LA has been described in patients with dense fibrous adhesions or short mesoappendix to avoid injury to the adjoining bowel or mesentery.9
References 1. Kirresh OZ, Nikolopoulos I, Oke T, Koshy S. Subhepatic appendicitis presenting with right upper quadrant pain. Br. J. Hosp. Med. (Lond.) 2012; 73: 593. 2. Nayak SB, George BM, Mishra S, Surendran S, Shetty P, Shetty SD. Sessile ileum, subhepatic cecum, and uncinate appendix that might lead to a diagnostic dilemma. Anat. Cell. Biol. 2013; 46: 296–8. 3. Ting JY, Farley R. Subhepatically located appendicitis due to adhesions: a case report. J. Med. Case. Rep. 2008; 2: 339.
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4. Palanivelu C, Rangarajan M, John SJ, Senthilkumar R, Madhankumar MV. Laparoscopic appendectomy for appendicitis in uncommon situations: the advantages of a tailored approach. Singapore Med. J. 2007; 48: 737–40. 5. Patel NR, Lakshman S, Hays TV, Thomas E. Subhepatic appendix with fecalith mimicking acute cholecystitis with gallstone. J. Clin. Ultrasound 1996; 24: 45–7. 6. Ong EM, Venkatesh SK. Ascending retrocecal appendicitis presenting with right upper abdominal pain: utility of computed tomography. World J. Gastroenterol. 2009; 15: 3576–9. 7. Ball WR, Privitera A. Subhepatic appendicitis: a diagnostic dilemma. BMJ Case Rep. 2013; 2013: pii: bcr2013009454. 8. Jada SK, Jayakumar K, Sahu PS, Vinoth R. Faecolith examination for spectrum of parasitic association in appendicitis. J. Clin. Diagn. Res. 2014; 8: 16–8. 9. Harissis HV, Georgiou GK. Submucosal resection of the appendiceal base. ANZ J. Surg. 2014; 84: 297–8.
Gabriel Rodrigues, MS, FRCS (Glasg) Faris Al Aswad, FRCS (Glasg), FRCS (Eng) Department of General Surgery, NMC Speciality Hospital, Dubai, UAE doi: 10.1111/ans.13122
© 2015 Royal Australasian College of Surgeons
Subhepatic appendicitis masquerading as acute cholecystitis: a lesson learnt! Subhepatic appendicitis can mimic other acute surgical abdominal conditions and can lead to a diagnostic dilemma. As surgery is the treatment of choice for appendicitis, establishing a proper diagnosis is of paramount importance especially to avoid dreadful complications like appendicular abscess, rupture and faecal peritonitis.1,2 This case illustrates the difficulty encountered in trying to diagnose acute appendicitis in patients whose appendix is mal-located during foetal development. We present this case of obstructive appendicitis, where in the diagnosis was established by radiological investigations and managed successfully. A 42-year-old man with diabetes presented with complaints of colicky right upper abdominal pain lasting for 2 days. He had three bouts of bilious vomiting and a low-grade fever. On examination, he was febrile (102°C) and tachycardic (110/min). Abdominal examination revealed a soft abdomen all over expect for tenderness, guarding and rigidity in the right hypochondrium. Murphy’s sign was positive with no mass palpable. There was no free fluid in the abdomen. Considering the symptoms and signs, a clinical diagnosis of acute cholecystitis was made. Blood investigations showed neutrophilia. An ultrasound (US) abdomen was done, which was inconclusive, but suspected acute calculous cholecystitis. A plain computed tomography (CT) scan of the abdomen was then done, which revealed an acutely inflamed tortuous subhepatic appendix with surrounding fat stranding and an obstructing faecolith (Fig. 1). Patient was subjected to an emergency laparoscopic appendectomy (LA) and the specimen was retrieved along with the faecolith (Fig. 2). Histopathology confirmed the diagnosis of acute appendicitis. Patient made a good post-operative recovery and on follow-up after 3 months is doing well. Acute appendicitis is one of the most common, easily diagnosed surgical emergencies and accounts for 1% of all surgical operations. Various appendicular positions that is retrocaecal (65.28%), pelvic (31%), subcaecal (2.26%), preileal (1%) and postileal (0.4%) have been described, but subhepatic position is a very rare position and is the result of a developmental anomaly (maldescent), where-in caecal descent towards the right iliac fossa is arrested and it lies in the subhepatic area.2,3 Palanivelu et al. reported an incidence of 0.08% subhepatic appendix among 7210 appendicitis in India.4 King in 1955 reported one of the early cases of subhepatic appendicitis.1 The diagnosis is usually missed preoperatively as it mimics acute cholecystitis and the presence of faecolith could be mistaken for gallstones on US abdomen, as in our patient.5 Abdominal CT is frequently required for diagnosis and has a high sensitivity (88– 100%) and specificity (92–98%).6 In situations where abdominal CT is inconclusive, clinical diagnosis of appendicitis remains doubtful and the patient remains clinically unwell, a diagnostic laparoscopy is © 2015 Royal Australasian College of Surgeons
Fig. 1. Plain computed tomography abdomen showing inflamed, tortuous subhepatic appendicitis with surrounding fat stranding (black arrow).
Fig. 2. Specimen of appendix with faecolith.
ANZ J Surg •• (2015) ••–••
2
recommended.4 Appendicular abscess is the most reported complication in this site and rupture is a rare event, which could happen because of a delay in diagnosis.7 Obstructive appendicitis can be due to a faecolith as in our patient or parasitic infestation, Ascaris lumbricoides being the commonest.8 LA can be easily performed in these patients, resulting in shorter hospital stay and less post-operative complications. When difficult or when complications are present, open appendectomy should be performed.4 Recently laparoscopic submucosal appendectomy, a modified technique of LA has been described in patients with dense fibrous adhesions or short mesoappendix to avoid injury to the adjoining bowel or mesentery.9
References 1. Kirresh OZ, Nikolopoulos I, Oke T, Koshy S. Subhepatic appendicitis presenting with right upper quadrant pain. Br. J. Hosp. Med. (Lond.) 2012; 73: 593. 2. Nayak SB, George BM, Mishra S, Surendran S, Shetty P, Shetty SD. Sessile ileum, subhepatic cecum, and uncinate appendix that might lead to a diagnostic dilemma. Anat. Cell. Biol. 2013; 46: 296–8. 3. Ting JY, Farley R. Subhepatically located appendicitis due to adhesions: a case report. J. Med. Case. Rep. 2008; 2: 339.
Images for surgeons
4. Palanivelu C, Rangarajan M, John SJ, Senthilkumar R, Madhankumar MV. Laparoscopic appendectomy for appendicitis in uncommon situations: the advantages of a tailored approach. Singapore Med. J. 2007; 48: 737–40. 5. Patel NR, Lakshman S, Hays TV, Thomas E. Subhepatic appendix with fecalith mimicking acute cholecystitis with gallstone. J. Clin. Ultrasound 1996; 24: 45–7. 6. Ong EM, Venkatesh SK. Ascending retrocecal appendicitis presenting with right upper abdominal pain: utility of computed tomography. World J. Gastroenterol. 2009; 15: 3576–9. 7. Ball WR, Privitera A. Subhepatic appendicitis: a diagnostic dilemma. BMJ Case Rep. 2013; 2013: pii: bcr2013009454. 8. Jada SK, Jayakumar K, Sahu PS, Vinoth R. Faecolith examination for spectrum of parasitic association in appendicitis. J. Clin. Diagn. Res. 2014; 8: 16–8. 9. Harissis HV, Georgiou GK. Submucosal resection of the appendiceal base. ANZ J. Surg. 2014; 84: 297–8.
Gabriel Rodrigues, MS, FRCS (Glasg) Faris Al Aswad, FRCS (Glasg), FRCS (Eng) Department of General Surgery, NMC Speciality Hospital, Dubai, UAE doi: 10.1111/ans.13122
© 2015 Royal Australasian College of Surgeons
