Rare disease

CASE REPORT

Subhepatic appendicitis: a diagnostic dilemma

William Robert Ball, Antonio Privitera

Department of Surgery, SUMMARY TREATMENT

University Hospital North A middle-aged woman was admitted with recurrent The patient underwent a diagnostic laparoscopy
Staffordshire, Stoke-on-Trent,
UK
episodes of ill-defined right-sided abdominal pain, more which revealed an inflammatory mass of appendicu-
prominent in the right upper quadrant. Surgical history lar origin that required mobilisation of the right
Correspondence to revealed a laparoscopic cholecystectomy, 1 month prior, colon and appendicectomy. Histology revealed
William Robert Ball, for gallstones that were thought to be the cause of her acute appendicitis with mucosal ulceration.
[email protected]
symptoms. However, she continued to experience similar
pain with exacerbation leading to readmission. Blood OUTCOME AND FOLLOW-UP
tests revealed increased inflammatory markers and an The patient made an uneventful recovery and was dis-
ultrasound scan showed a tubular hypoechoic structure charged on the third postoperative day. However, she
between her right kidney and liver corresponding to the was readmitted 7 days postdischarge complaining of
area of maximal tenderness. A diagnostic laparoscopy abdominal pain, distension and vomiting. A CT scan
was performed and a subhepatic inflammatory mass of was requested and this revealed an ileus. This settled
appendicular origin was found. This required with conservative treatment and the patient was dis-
mobilisation of the right colon and appendicectomy. charged with no further complications.
The patient made an uneventful recovery after being
readmitted for an ileus treated conservatively. Histology DISCUSSION
revealed acute appendicitis with mucosal ulceration. Palanivelu et al1 reported the incidence of subhepa-
tic appendix at 0.08% from their study of 7210
patients. In 1955, King2 reported the first case of
BACKGROUND subhepatic appendicitis due to non-descent of the
Appendicitis is a common acute surgical condition. caecum. Since then, only a few isolated cases have
Normal appendix anatomy and classical presenta- been described in the literature.3 4 There have been
tion are well documented but aberrations exist as reports of intestinal mal-rotation rather than non-
evidenced by the published literature.1–6 A high descent of the caecum as a cause of this anatomical
index of suspicion and awareness of these anatom- variant.5 6 Subhepatic appendicitis does not present
ical variants is necessary in order to correctly diag- in the classical way and as such can be mistaken for
nose and safely manage appendicitis. other conditions including biliary pathology. Also,
subhepatic appendicitis seems to present more
often in the elderly adding further uncertainty to
CASE PRESENTATION the diagnosis.7 In many circumstances it runs a
A middle-aged woman was admitted with recurrent chronic course with ill-defined right flank and right
episodes of ill defined right-sided abdominal pain, upper quadrant pain and diagnosis is often made at
more prominent in the right upper quadrant. She laparoscopy. Perforation and abscess formation are
was not having a fever and was haemodynamically significant complications owing to late diagnosis.5 6
stable. Her medical history included diabetes and
hypertension and her surgical history revealed a
laparoscopic cholecystectomy for gallstones
Learning points
1 month prior.

▸ A high index of suspicion is needed to

INVESTIGATIONS diagnose subhepatic appendicitis since this
Blood tests were requested and these showed a clinical presentation may mimic other
white cell count of 13.1×109/L and C reactive conditions including biliary pathology.
protein of 36 mg/L. An ultrasound scan was per- ▸ This condition can run a chronic course and
formed revealing a tubular hypoechoic structure has a high incidence of perforation and
between her right kidney and liver corresponding abscess formation making operative
to the site of maximal tenderness. The operation intervention challenging.
note for the laparoscopic cholecystectomy per- ▸ Diagnostic laparoscopy is a valuable tool in
formed 1 month prior made no mention of an cases of atypical abdominal pain.
abnormally positioned appendix.
To cite: Ball WR,
Privitera A. BMJ Case Rep
DIFFERENTIAL DIAGNOSIS Competing interests None.
Published online: [please
include Day Month Year] ▸ Cholecystitis Patient consent Obtained.
doi:10.1136/bcr-2013- ▸ Appendicitis Provenance and peer review Not commissioned; externally peer
009454 ▸ Pyelonephritis reviewed.

Ball WR, et al. BMJ Case Rep 2013. doi:10.1136/bcr-2013-009454 1

 Rare disease

REFERENCES 5 Galván-Montaño A, Flores-Nava G, Suárez-Roa Mde L, et al. Subhepatic appendicitis

1 Palanivelu C, Rangarajan M, John SJ, et al. Laparoscopic appendectomy for with subdiaphragmatic abscess in a pediatric patient without intestinal malrotation:
appendicitis in uncommon situations: the advantages of a tailored approach. case report. Cir Cir 2010;78:79–81.
Singapore Med J 2007;48:737–40. 6 Rappaport WD, Warneke JA. Subhepatic appendicitis. Am Fam Physician
2 King A. Subhepatic appendicitis. AMA Arch Surg 1955;71:265–7. 1989;39:146–8.
3 Isreb S, Holtham S. Incidental finding of an anterior sub-hepatic appendix during 7 Ting JY, Farley R. Subhepatically located appendicitis due to adhesions: a case report.
laparoscopic cholecystectomy. BMJ Case Rep. Published Online 21 Sep 2010. J Med Case Rep 2008;2:339.
doi:10.1136/bcr.04.2010.2883
4 Montes-Tapia F, Quiroga-Garza A, Abrego-Moya V. Primary torsion of the vermiform
appendix and undescended cecum treated by video-assisted transumbilical
appendectomy. J Laparoendosc Adv Surg Tech A 2009;19:839–41.

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2 Ball WR, et al. BMJ Case Rep 2013. doi:10.1136/bcr-2013-009454