Malrotated Subhepatic Caecum with Subhepatic Appendicitis: Diagnosis and Management

Abstract

Subhepatically located caecum and appendix is a very rare entity. It occurs due to the anomaly in fetal gut rotation that results in an incomplete rotation and fixation of the intestine. Appendicitis, which is a common surgical emergency, in combination with the abnormal subhepatic location, presents a great challenge in its diagnosis and management. Here, we describe a 42-year-old male with chronic dyspepsia who presented with sepsis and severe pain at his right hypochondriac and epigastric region. The final diagnosis was acute appendicitis of the subhepatic appendix. Our discussion focuses on the diagnostic approach and clinical and surgical management. We hope that our report will increase the awareness among the clinicians and hasten the management of such rare condition to avoid complications.

Clinical Experience of Diagnosis and Surgical Treatment of 6 Cases of Acute Subhepatic Appendicitis

“…There were 6 patients in this group, 5 males and 1 female, aged from 21 to 64 years (44.2 ± 17.6 years) [ 3 ]. Medical history: the time from onset to treatment was 7∼56 h, with an average of 30.6 h. Clinical manifestations: all of them showed pain in the right upper abdomen, and other symptoms included fever (4 cases), nausea and vomiting (3 cases), radiation pain in the right shoulder and back (2 cases), diarrhea (1 case), and cessation of anal exhaust and defecation (3 cases) [ 4 , 5 ]. Physical examination: deep tenderness in the right upper abdomen or right middle abdomen (5 cases), percussion pain in the right liver area (1 case) [ 6 – 8 ].…”

Rare appendiceal escapades in childhood: the Grande experience!

“…Rarer positions include sub-hepatic, lateral pouch, mesocoeliac, left-sided and intraherniary, with reported incidence of SHA being 0.08% [ 16 ]. This was first reported by King in 1955 [ 15 , 17 ].…”

Is the laparoscopic approach appropriate for pediatric subhepatic appendicitis?

“…In our series, the incidence was higher (3.2%) than revealed by previous studies. There have been only a few cases of subhepatic appendicitis described previously in children . To our knowledge, our study includes the largest number of subhepatic laparoscopic appendectomies in pediatric patients reported in the literature.…”