Perforated sub-hepatic appendix; rare presentation of a common disease

Area of Science:

• Gastroenterology
• Abdominal Imaging
• Surgical Case Reports

Background:

• Appendicitis typically presents with right lower quadrant pain, but variations in anatomy can lead to atypical presentations.
• Subhepatic collections can mimic other pathologies like liver abscesses, necessitating advanced imaging for accurate diagnosis.

Observation:

• An elderly male presented with persistent right upper quadrant pain and nausea, exhibiting localized tenderness.
• Initial investigations revealed leukocytosis and a subhepatic collection on ultrasound, with no signs of systemic infection.
• A history of a similar, self-resolving episode suggested a recurrent or atypical inflammatory process.

Findings:

• Computed tomography (CT) scan confirmed a perforated appendix in the subhepatic space, distinct from initial differential diagnoses.
• The subhepatic collection was directly associated with the perforated appendiceal stump.

Implications:

• This case highlights the importance of considering appendicitis in atypical locations, especially in the elderly.
• CT imaging is crucial for differentiating subhepatic collections and guiding appropriate management.
• Conservative treatment, including antibiotics and percutaneous aspiration, can be effective for contained appendiceal abscesses.