Appendicitis – Is a Clinical Diagnosis Enough?

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J Acute Care Surg. 2023;13(1):32-34

Publication date (electronic) : 2023 March 21

doi : https://doi.org/10.17479/jacs.2023.13.1.32

Caren D’Souza, Supriya Pinto, Midhun Kumar

Department of General Surgery, KS Hegde Medical Academy, Nitte University, Karnataka, India

^*Corresponding Author: Supriya Pinto, Department of General Surgery, KS Hegde Medical Academy, Nitte University Mangalore-575018, Karnataka, India, E-mail: supriyapinto@gmail.com

Received 2022 August 22; Revised 2022 November 18; Accepted 2023 February 2.

Abstract

Introduction

Appendicitis is one of the most common surgical emergencies and a common cause for abdominal pain. Though the common presentation is pain in the right iliac fossa with rebound tenderness, this may vary depending on the location of the appendix and the severity of the disease. The common location of the appendix is in the retrocecal position (65.3%). However, other positions of the appendix have been reported including subhepatic, lateral pouch, meso-celiac, left-sided, lumbar, and pelvic region [1]. These atypical positions result in unusual clinical features causing a delay in diagnosis and unfavorable complications such as perforation and abscess formation. We present two cases of atypical appendices in the subhepatic space with varying presentations.

Case 1

An 18-year-old boy otherwise healthy, presented to KS Hegde Medical Academy Outpatient Department with pain in his abdomen. The pain was associated with a few episodes of vomiting, and a fever for 5 days. The patient was treated symptomatically with intravenous antibiotics in a nearby hospital and discharged. The pain continued, and he came to our Outpatient Department. On clinical examination, he was afebrile, with stable vitals. He had mild tenderness in the right lumbar and right hypochondrium, no rebound tenderness or guarding was noted. The right iliac fossa had no tenderness or mass. In the initial work-up, the white blood cell count was 10,000 cells/mm³ indicating neutrophilia. Ultrasonography was performed and revealed a 7 mm inflamed appendix which was coursing superiorly along the para-cecal region and reaching up to the hypochondrium with its tip abutting the inferior margin of the liver.

A diagnosis of an abnormally located subhepatic appendix was made and the patient was posted for laparoscopic appendicectomy. Intraoperatively, we found a short ascending colon with the caecum lying in the lumbar region and appendix in the subhepatic region next to the gall bladder (Figure 1). An appendicectomy was performed and patient was discharged the next day. Histopathology revealed features of acute on chronic appendicitis. The patient was asymptomatic during the follow up, at one week and two months.

Figure 1

Subhepatic appendix noted next to the gallbladder.

Case 2

A 69-year-old agriculturist, presented with a three-day history of abdomen pain and vomiting. He had tachycardia of 125 beats/minute, and blood pressure measuring 100/70 mmHg. On abdominal examination, he had guarding in the upper abdomen with sluggish bowel sounds. His white blood cell count was elevated (17,000 cells/mm³) with neutrophilia. An erect abdomen X ray revealed free air under the diaphragm. Contrast enhanced computerized tomography (CECT) of his abdomen revealed free fluid in the right paracolic gutter and the subhepatic space. A diagnosis of hollow viscus perforation was made. He underwent an emergency laparotomy. Intraoperatively, gross contamination in the right subdiaphragmatic space, Morrisons pouch, and the right paracolic gutter was noted. A perforated appendix adherent to the hepatic flexure was noted with a short ascending colon and pulled up caecum (Figure 2). An appendicectomy was performed, followed by a thorough peritoneal wash. A drain was placed in the pelvis. Histopathology revealed features of acute appendicitis. The postoperative period was uneventful and he was discharged on postoperative Day 7. The patient was asymptomatic during the follow up of 1 month.

Figure 2

Perforated appendix noted in the subhepatic location.

Discussion

Acute appendicitis is usually a clinical diagnosis based on signs, symptoms, clinical history, physical examination, and results of laboratory tests. Basic imaging like ultrasonography is usually performed to confirm it. However, in patients with atypical clinical features, due to an abnormal position of the appendix, imaging using CECT play an important role in preoperative diagnosis and determination of the appropriate treatment. The common location of the appendix is retrocecal (65.3%). However, other positions have been reported including subhepatic, lateral pouch, meso-celiac, left-sided, lumbar, and the pelvic region [1].

Appendicitis in the subhepatic space (i.e., subhepatic appendicitis) is not common, and it occurs because of intestinal malrotation and/or non-descent of the cecum during embryonic development [1,2]. In 1955, King reported the first case of subhepatic appendicitis due to non-descent of the caecum [2]. Since then, only a few isolated cases have been described in the literature. Subhepatic appendicitis may present with right upper abdominal pain often mimicking cholecystitis, liver abscess, pyelonephritis, or lumbar pain [3–5]. There have been reports of the appendix found in the subhepatic space as an inflamed appendix or as a mass during a laparoscopic / open cholecystectomy [4,6]. Perforation and abscess formation are significant complications of subhepatic appendicitis leading to late diagnosis [6].

Ultrasonography may or may not be sensitive enough to detect the subhepatic appendix depending on location bias. When in doubt of equivocal findings, a CT scan of the abdomen is a good diagnostic modality to identify subhepatic appendicitis [1].

The laparoscopic appendicectomy is a preferred modality of treatment in such conditions because there is a reduced incidence of postoperative ileus, lower frequency of surgical wound infection, shorter duration of hospitalization, decreased adhesions, and faster recovery compared with an open appendicectomy. If a subhepatic perforated appendix is diagnosed by imaging, image guided aspiration of the collection with conservative management has also been reported [7].

Conclusion

Even though appendicitis is a clinical diagnosis, in a patient with atypical presentation with respect to varying position of the appendix, CECT imaging should be considered in the diagnosis. This would certainly help in early management and decrease the incidence of unfavorable complications before the diagnosis of appendicitis.

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