Ascending retrocecal appendicitis presenting with right upper abdominal pain: Utility of computed tomography

Abstract

Acute appendicitis is a common surgical condition that is usually managed with early surgery, and is associated with low morbidity and mortality. However, some patients may have atypical symptoms and physical findings that may lead to a delay in diagnosis and increased complications. Atypical presentation may be related to the position of the appendix. Ascending retrocecal appendicitis presenting with right upper abdominal pain may be clinically indistinguishable from acute pathology in the gallbladder, liver, biliary tree, right kidney and right urinary tract. We report a series of four patients with retrocecal appendicitis who presented with acute right upper abdominal pain. The clinical diagnoses at presentation were acute cholecystitis in two patients, pyelonephritis in one, and ureteric colic in one. Ultrasound examination of the abdomen at presentation showed subhepatic collections in two patients and normal findings in the other two. Computed tomography (CT) identified correctly retrocecal appendicitis and inflammation in the retroperitoneum in all cases. In addition, abscesses in the retrocecal space (n = 2) and subhepatic collections (n = 2) were also demonstrated. Emergency appendectomy was performed in two patients, interval appendectomy in one, and hemicolectomy in another. Surgical findings confirmed the presence of appendicitis and its retroperitoneal extensions. Our case series illustrates the usefulness of CT in diagnosing ascending retrocecal appendicitis and its extension, and excluding other inflammatory conditions that mimic appendicitis.

Suprapubic single-incision laparoscopic appendectomy: a nonvisible-scar surgical option

“…When performing an appendectomy with a view through the umbilicus, sometimes the right Toldt's fascia needs to be partially opened to expose completely the appendix before starting dissection of the mesoappendix safely and avoid inadvertent injury to the cecum. On the other hand, the appendix occupies a retrocecal position in 26-65% of patients with acute appendicitis [12]. Acute retrocecal appendicitis may lead to delayed diagnosis and complications, including abscess formation (purulent or gangrenous acute appendicitis in 66% of cases in our series) which obscures identification and section of the appendicular base and frequently requires mobilization of the right colon.…”

Computed Tomography (CT) Findings of a Diagnostic Dilemma: Atypically Located Acute Appendicitis

“…Inguinal canal, femoral canal, subhepatic, retrocecal, intraperitoneal abdominal midline and left side in situs inversus or intestinal malrotation patients are among these localisations [4,6]. This can lead to atypical clinical presentations and cause a diagnostic dilemma.…”

Unusual manifestation of acute retrocecal appendicitis: Pericholecystic fluid

“…[5] The most common position of the appendix is intraperitoneal, and the second is in the retrocecal region. [3,6] More than 50% of the patients with retrocecal appendicitis can present with atypical findings. [2] This condition could even mimic acute cholecystitis or gallbladder perforation.…”

“…[2] This condition could even mimic acute cholecystitis or gallbladder perforation. [3,7] Although US should be the first-line choice in the diagnosis of acute appendicitis, it might be inadequate in retrocecal appendicitis. [4] Moreover, as US is a rapid technique and it is significantly operator-dependent, [4] MDCT could be useful in such patients.…”

“…[2] When the appendix is in the retrocecal position, the signs and symptoms of acute appendicitis might be atypical and could mimic right flank and hypochondriac pathologies including acute cholecystitis, diverticulitis, acute gastroenteritis, ureteral colic, acute pyelonephritis, intestinal neoplasia, and irritable bowel syndrome. [3] Rapid and precise diagnosis could reduce the morbidity and mortality of acute appendicitis. [1] Here, we present a case of acute subhepatic-retrocecal appendicitis, in whom clinical and sonographic findings mimicked acute cholecystitis.…”