Subhepatically located appendicitis due to adhesions: a case report

Atypical Presentation and Diagnostic Challenges of Appendicitis in an 85-Year-Old Male: A Case Report

Acute appendicitis in elderly individuals is uncommon and poses a significant challenge due to atypical symptomatology. An 85-year-old male presented to the emergency department (ED) with abdominal pain associated with nausea and reduced oral intake. Physical examination revealed diffuse abdominal tenderness. He was initially treated for constipation with an enema and discharged. Two days later, the patient returned with worsened pain and a new onset of fever. Examination revealed guarding. Lab results showed significant elevation in C-reactive protein (CRP) and white blood count (WBC). A contrast-enhanced computed tomography (CT) scan showed evidence of a perforated appendix. He was admitted into the surgical ward and improved on conservative treatment. This case describes an atypical presentation of acute appendicitis in an elderly patient, emphasizing the importance of recognizing unusual presentations in this population. Early use of contrast-enhanced CT scans is crucial for accurate diagnosis and improving patients outcomes.

Thermal Injury to the Subhepatic Appendix Following Percutaneous Ultrasound-Guided Radiofrequency Ablation for Hepatocellular Carcinoma: A Case Report

We present the first documented case of a fistula between the treated zone and the appendix after RFA in a patient with HCC. Contrast-enhanced CT and MRI revealed a subcapsular hepatic nodule with image findings of HCC located adjacent to the ascending colon and cecum. An ultrasound-guided core needle biopsy was subsequently performed to distinguish between hepatic metastasis and HCC. Post-RFA imaging identified a low-attenuating ablated area adjacent to an air-filled appendix. The patient later experienced complications, including increased liver enzymes and an abscess at the ablation site. Imaging revealed a fistulous tract between the RFA zone and the appendix. Over the following months, the patient underwent conservative treatment involving intravenous antibiotics and repeated percutaneous drainage, exhibiting eventual symptom relief and an absence of the fistulous tract upon subsequent imaging. This case highlights the rare complications that can arise during RFA due to peculiar anatomical variations, such as a subhepatic appendix, resulting from midgut malrotation and previous surgery. It is imperative for operators to be cognizant of potential anatomical variations when considering RFA treatment, ensuring comprehensive pre-procedural imaging and post-procedure monitoring. This case also emphasizes the potential viability of nonoperative management in complex scenarios in which surgical interventions pose significant risks.

Retro-psoas appendicitis

The vermiform appendix (VA) is known to exhibit a wide range of anatomic variability, with clinical presentation correlating with certain known anatomic positioning. To the best of our knowledge, we describe the second known case of a retro-psoas muscle VA variant and the first known case of appendicitis in such a location. Retroperitoneal access was obtained, and the appendix was freed from the intermuscular recess between the psoas and iliacus. The peritoneal defect was primarily repaired, and the patient was discharged on postoperative day 1 in good condition.

Computed tomography evaluation of variations in positions and measurements of appendix in patients with non-appendicular symptoms: time to revise the diagnostic criteria for appendicitis

Purpose

To estimate the frequency distribution of different anatomical positions, and to measure the diameter, wall thickness, and length of appendix in patients with non-appendicular symptoms.

Material and methods

This retrospective observational study was conducted among 1,575 patients, who had undergone computed tomography (CT) scan of abdomen for various non-appendicular signs and symptoms. Frequency of distribution of different anatomic locations and measurements of various morphologic parameters were recorded.

Results

The most common location of appendix was retrocecal, followed by sub-cecal, post-ileal, and pelvic locations. The mean length of appendix was 66.7 mm (range, 6.3-123 mm), and the diameter was 6.3 mm (range, 2.8-11.3 mm). Diameter of > 6 mm was noted in 48.12% patients. The mean wall thickness was 2.37 mm, ranging 1.2-4.2 mm. The most common intra-luminal content was air-mixed with hypodense or hyperdense material observed in 70.5% of cases.

Conclusions

Although an appendix with diameter less than 6 mm may be considered normal, a diameter above 6 mm has an overlap between a normal and inflamed appendix. Therefore, it should be considered in association with clinical and secondary findings to avoid overdiagnosis and unnecessary appendicectomies. We strongly recommend that diameter-based CT criteria to diagnose appendicitis should be revised and standardized.

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

To summarize the experience of diagnosis and surgical treatment of 6 cases of acute subhepatic appendicitis. The clinical data of 6 patients with subacute appendicitis in Zhejiang Provincial People's Hospital from July 2018 to December 2019 were analyzed retrospectively. Results. There were 5 males and 1 female. All 6 cases were diagnosed as appendicitis by abdominal CT before operation. All patients underwent laparoscopic appendectomy without conversion to laparotomy. One case of ectopic appendix was located under the liver with absence of ascending colon, one case of ectopic appendix was located under the liver with ectopic ascending colon of transverse colon, one case of appendix head was located in the liver cyst, and the resection of liver cyst was performed at the same time, and three cases of retrocolonic appendix head were located under the liver. Postoperative pathology confirmed appendicitis. For patients with right upper abdominal pain and tenderness, the possibility of subhepatic appendicitis should be considered before operation. Emergency abdominal CT has more advantages than ultrasound. Laparoscopy can not only make a definite diagnosis but also perform appendectomy at the same time.

A pictorial essay of the most atypical variants of the vermiform appendix position in computed tomography with their possible clinical implications

Purpose

The tip of the appendix may be located in various areas of the abdominal cavity due to its variable length and/or the changeable position of the caecum. Although in the case of an atypical position the tip is usually located behind the caecum, there are possible locations that occur very rarely. Therefore, in the case of appendicitis the symptoms may lead to the wrong diagnosis. The aim of this study is to present the most atypical locations of the tip of the appendix found on CT (computed tomography) scans and thus help to avoid misdiagnoses.

Imaging findings

The most unusual locations of the tip of the appendix found in healthy subjects included: left inferior quadrant, along the lower edge of the liver near the gallbladder and the right kidney, the tip touching the duodenum, the rectum or appendages, and a long appendix located in the scrotum as the content of a hernia. In these positions, appendicitis may mimic acute diverticulitis, cholecystitis, duodenal ulcer, duodenitis, enteritis, or adnexal or testis pathologies.

Conclusions

It is important to be aware of atypical locations of the appendix because appendicitis in an unusual area may mimic other acute abdominal diseases and delay the proper treatment.

A rare case of perforated "sub-hepatic appendicitis" - a challenging differential diagnosis of acute abdomen based on the combination of appendicitis and maldescent of the caecum

Unusual locations of the appendix vermiformis can result in delay in appropriate diagnosis and treatment of appendicitis. So an inflamed appendix in a sub-hepatic caecum caused by caecal maldescent for example can mimic cholecystitis, the pain being localized in the right upper quadrant. Here, we present a case of perforated sub-hepatic appendicitis with peritonitis, requiring open ileocaecal resection. Review of the existing literature has demonstrated that this pathology is uncommon, yet not so rare as one might presume. In conclusion, surgeons should be aware of this possibility in the diagnostic and therapeutic management of acute abdomen.

Variations in the position and length of the vermiform appendix in a black kenyan population

Background. Topography of the appendix influences its mobility, degree of mobilization of the cecum, and need for additional muscle splitting during appendectomy. Although appendectomy is a common surgical procedure, there is a paucity of data on its topography in black Africans. Methods. The position and length of the appendix and relation of the appendicular base with spinoumbilical line were determined in 48 cadavers obtained from the Department of Human Anatomy, University of Nairobi, Kenya. Results. The commonest appendicular types in males were retrocecal 10 (27%) while in females was subileal 4 (36.4%). The average length of the appendix was 76.5 ± 23.6 mm. The base of the appendix was located along, below, and above the spinoumbilical line in 25 (52.1%), 9 (18.8%), and 14 (29.2%) cases, respectively. Conclusion. The topography of appendix in Kenyans shows variations from other populations. Knowledge of these variations is important during appendicectomy.

A mystifying mass

A 57-year-old male was referred by his general practitioner (GP) to hospital with right upper quadrant pain and a palpable mass (10 × 9 cm). He had been assessed by his GP several weeks earlier and represented as initial treatment failed. On his second presentation a mass was evident and thought to represent cholecystitis by the referring GP. However, the correct and prompt use of appropriate radiological imaging enabled swift diagnosis and management of atypical acute appendicitis through microbial specific therapy. Atypical appendicitis delays diagnosis and treatment which represents greater levels of appendiceal ischaemia and heightened perforation risk. This case study highlights the non-surgical management of acute atypical appendicitis and also reinforces the use of appropriate imaging modalities.

Perihepatic abscess caused by dropped appendicoliths following laparoscopic appendectomy: sonographic findings

We report the case of a 6-year-old girl presenting with acute appendicitis complicated by perforated appendix, followed by perihepatic abscess associated with ectopic appendicoliths. CT findings were initially suspicious for an intrahepatic abscess with internal calcifications. However, on sonography the abscess appeared to be in a perihepatic location. Perihepatic abscess associated with a dropped or retained appendicolith has been rarely reported. Awareness of the possibility of a perihepatic abscess as a complication of laparoscopic appendectomy and use of sonography should result in optimal management of this rare complication.

Subhepatic appendicitis: a diagnostic dilemma

A middle-aged woman was admitted with recurrent episodes of ill-defined right-sided abdominal pain, more prominent in the right upper quadrant. Surgical history revealed a laparoscopic cholecystectomy, 1 month prior, for gallstones that were thought to be the cause of her symptoms. However, she continued to experience similar pain with exacerbation leading to readmission. Blood tests revealed increased inflammatory markers and an ultrasound scan showed a tubular hypoechoic structure between her right kidney and liver corresponding to the area of maximal tenderness. A diagnostic laparoscopy was performed and a subhepatic inflammatory mass of appendicular origin was found. This required mobilisation of the right colon and appendicectomy. The patient made an uneventful recovery after being readmitted for an ileus treated conservatively. Histology revealed acute appendicitis with mucosal ulceration.