Hidden appendix: A case report and literature review of perforated acute appendicitis masquerading as acute cholecystitis

Abstract

Introduction

Acute appendicitis of the subhepatic appendix is uncommon, and a preoperative diagnosis is difficult without a thorough understanding of the various anatomical locations. Cross-sectional imaging is indispensable for prompt diagnosis and subsequent treatment. Surgery is the standard treatment for perforated appendicitis in the subhepatic region. In this study, we present a case of subhepatic appendicitis with an unusual presentation.

Case presentation

A 28-year-old man presented to our emergency department with a 3-day history of diffuse right abdominal discomfort, diarrhea, fever, and vomiting. Physical examination revealed rebound soreness and guarding in the right upper and lower quadrants. Laboratory tests revealed high levels of C-reactive protein and serum bilirubin and neutrophilic leukocytosis. Abdominal computed tomography revealed an undescended cecum and a subhepatic appendix with an intraluminal appendicolith, fat stranding, and peri-appendiceal fluid. The patient underwent open exploration and appendicectomy, during which the subhepatic perforated appendix was excised. The patient's recovery was uneventful.

Discussion

Atypical presentations may indicate an unusual anatomical placement of the appendix. Preoperative diagnosis using cross-sectional computed tomography imaging and a thorough understanding of these situations frequently result in early diagnosis and expeditious surgical care.

Conclusion

Surgical crises resulting from aberrant anatomical variations of the appendix constitute a distinct diagnostic challenge. A strong index of suspicion for this uncommon presentation permits early surgical intervention and prevents delay-induced morbidity/mortality.

Highlights

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  Appendicitis classically presents with right iliac fossa pain.

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  Anomalous positions of the appendix can give rise to clinical challenges.

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  Perforation in subhepatic appendicitis masquerades as acute cholecystitis.

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  Undescended cecum could give rise to the rare anatomical position of the appendix.