Difficult diagnosis of acute abdomen caused by sub hepatic caecum with acute appendicitis—A rare case report

Highlights

• •Sub hepatic appendicitis does not present in the usual way.
• •Complications are common due to difficulty in diagnosis and thus delay in surgery.
• •CT is specific, however diagnostic laparoscopy should be done if in doubt.
• •High index of suspicion in right upper abdominal pain with difficulty in diagnosis.

Abstract

Sub hepatic caecum and appendix is an uncommon condition. It occurs due to incomplete rotation of foetal foregut and mal descent of caecum. This condition may be mistaken for acute cholecystitis, liver abscess, duodenal perforation or right renal calculus. Diagnosis may be delayed when acute appendicitis develops complications - appendicular rupture, perforation or localized abscess. The condition may be missed on ultra sound and CT abdomen may be inconclusive. Thus, surgeon should have a high index of suspicion in such undiagnosed right upper abdominal pain. In such cases an early diagnostic laparoscopy is suggested to avoid further complications. The present case is being reported due to difficulty in diagnosis of the condition, need for timely surgical intervention to avoid life threatening complications.

1. Introduction

Sub hepatic appendicitis is rare condition [1]. The incidence of sub hepatic appendicitis has been found to be .08% out of all appendectomy. This equals to an annual incidence of .09 per 100000 population [2]. King in 1955 described the anomaly and reported the first case. He also mentioned the condition having been documented in 1863 [3]. This anomaly occurs due to incomplete rotation and mal descent of the foetal foregut. Due to non-perception and inadequacies in the diagnosis the condition presents as appendicular rupture, localised sub hepatic abscess or sepsis [[1], [2], [3],5,6]. This case is being presented to create more awareness amongst surgeons regarding this uncommon condition, so that timely diagnosis and management is carried out.

2. Case report

A 31-year healthy male came to the emergency service with h/o severe pain in right side of abdomen off and on for last 2 days. He also had nausea, fever and decreased oral acceptance. Initially he consulted a local physician where a USG abdomen was done. It reported acute appendicitis.

He was a non-smoker with no significant medical history, no h/o allergies or family history.

On examination he had tenderness in right para-umbilical and sub-costal area. Psoas test was negative. B/S were normal pitched and he had no signs of free fluid in the peritoneal cavity.

His blood counts showed TLC 12600 with P 88%, serum amylase and lipase were normal. A CECT abdomen was done that reported high para caecal appendicitis.

The findings and management plan were discussed with the patient and their care giver. Informed consent was taken, patient prepared and shifted for surgery.

Laparoscopic surgery was done in supine position and under general anaesthesia.

3 Ports (one 10 mm and two 5 mm) were used. 10 mm port was sub-umbilical and 5 mm ports in both iliac fossae. On initial inspection caecum and appendix could not be found as those were missing in right iliac fossa region. On further exploration ileo-caecal junction was found in sub hepatic location. Appendix was grossly inflamed and had mild adhesions. The tip of appendix reached in the right lumbar area. It was mobilized, meso-appendix divided with harmonic ace and the base of appendix was tied with 2 endo loops. The base was divided. The 10 mm telescope was taken out and a 5 mm telescope with mounted camera was introduced through the left iliac fossa port. Appendix was extracted out through the 10 mm sub umbilical camera port. Complete haemostasis was secured, sub hepatic lavage done and procedure completed.

Post-operative period was uneventful and patient discharged on D3.

Histo-biopsy report revealed acute appendicitis with peri appendicitis.

3. Discussion

Sub hepatic caecum results due to incomplete rotation and fixation/mal descent of foetal foregut [[4], [5], [6]]. The D/D include acute cholecystitis, liver abscess, perforated duodenal ulcer and right renal calculus. This underlines the need for radiologic imaginary. USG may be the mostly used diagnostic tool, however CT scan has the most sensitivity in the diagnosis [1]. In many cases diagnosis is made at laparoscopy specially where CT scan is inconclusive [3,7]. Han N Beh reported acute appendicitis in right upper quadrant caused by renal agenesis [8]. Singh S reported a case of right upper abdominal pain that was misdiagnosed on CT [9]. Ong et al. reported 4 cases of right upper abdominal pain reported as acute cholecystitis and sub hepatic abscess on U/S. These were confirmed to have sub hepatic appendicitis on CT scan [10]. Incidental presence of sub hepatic appendix during course of open cholecystectomy was reported by Khan IA and Nasir M [11].

Declaration of Competing Interest

No conflicts of interest.

Funding

This research did not receive any specific grant from funding agencies in the public, Commercial, or not-for-profit sectors.

Ethical approval

The study is exempt from ethical approval.

Consent

Written informed consent was obtained from the patient for publication of this case report and accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal on request.

Author contribution

Operating surgeon: Guru Prasad Painuly.

Design and idea: Guru Prasad Painuly, Mini Singhal.

Drafting: Guru Prasad Painuly.

Data acquisition: Guru Prasad Painuly, Mini Singhal.

Final revision: Guru Prasad Painuly, Mini Singhal.

Registration of research studies

NA.

Guarantor

Corresponding author is the guarantor of submission.