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Clinical Case: Subhepatic Cecum with Subhepatic Appendicitis - want to learn more about it?

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Clinical Case: Subhepatic Cecum with Subhepatic Appendicitis

Many structures of the body are not carved in stone regarding their anatomy. The position and appearance of certain body parts may vary, and there is an entire spectrum of anatomical variations of some organs. This clinical case presents a man with an anatomical variation of vermiform appendix and cecum, which have drawned attention only after they were inflamed.

Also, what you will understand through this article is the importance of differential diagnostics and gradual reaching the accurate diagnosis by using the different diagnostic methods and excluding initial presumptions.

Key Facts
Abdominal quadrants & regions Superficial divisions used for orientation during clinical examination.
4 quadrants: right upper, right lower, left upper, left lower
9 regions: hypochondrium (2), epigastric (1), lumbar (2), umbillical (1), inguinal (2), hypogastric (1)
Hepatorenal pouch of Morison Space between the liver and right kidney. It is normally empty, but excessive fluid in the peritoneal cavity can lead to the fluid accumulation in the pouch as well, which is life-threatening situation.
Differential diagnostics to peptic ulcer

Perforated peptic ulcer signs and symptoms: pain in epigastric and right hypochondriac regions, dyspepsia, fluid in Morison's pouch, presence of air under the diaphragm

Suphepatic appendicitis signs and symptoms: pain in epigastric and right hypochondriac regions, dyspepsia, fluid in Morison's pouch, absence of air under the diaphragm

Ethiology & presentation of appendicitis Ethiology: usually fecalith obstructing fluid drainage from appendix
Presentation: in early stage the pain migrates from the umbilical region to the right inguinal. Later, pain is in the exact location of inflamed appendix (normally at McBurney’s point on the abdominal wall)
Guarding A state where the patient tends to keep his abdominal muscles tense to prevent movement of the abdominal wall because of the strong pain
Incomplete malrotation and fixation Any variation of the normal rotation and fixation (R&F) of the GI tract. The normal R&F reffers to the 270º counterclockwise rotation around the superior mesenteric vessels during fetal development.

After reviewing this case you should be able to describe the following:

  • Describe the meaning and boundaries of the abdominal quadrants and regions.
  • Describe the location and significance of the hepatorenal pouch of Morison. 
  • Explain why the results of the ultrasound exam were nonspecific, what was the significance of the absence of free air under the diaphragm, and why the preliminary diagnosis was a peptic ulcer.
  • Describe the etiology of appendicitis and what “guarding” means.
  • Describe the etiology of GI anomalies relative to incomplete (malrotation) and fixation.

This article is based on a case report published in the Journal "Case Reports in Surgery" in 2015, by Caroline C. Jadlowiec, Beata E. Lobel, Namita Akolkar, Michael D. Bourque, Thomas J. Devers, and David W. McFadden.

Case description

A 42-year-old man presented with severe pain in his epigastric and right hypochondriac region. He had a history of chronic dyspepsia. The two painful abdominal regions were tender to touch but the patient did not exhibit guarding. An erect PA chest radiograph showed no free air under the diaphragm. Subsequently, an abdominal ultrasound was performed, and it showed some fluid in the hepatorenal pouch of Morison

Preliminary diagnosis of a perforated peptic ulcer was considered. However, an abdominal and pelvic CT series revealed a thickened tubular structure located retrocecally and subhepatically in the right hypochondriac region (Figures 1&2).

Figure 1. Coronal (A) and Sagittal (B) CT images showing the subhepatic inflamed appendix (arrows).

A diagnosis was then made of acute inflammation of a subhepatic appendix. A diagnostic laparoscopy was done with an attempt to perform laparoscopic appendectomy but the procedure eventually converted to open appendectomy through a transverse incision at the right upper lumbar region and the patient recovered uneventfully.

Figure 2. Axial CT showing inflamed appendix.

Anatomical considerations

Figure 3. Vermiform appendix.

A subhepatically located appendix and cecum is a rare anatomical variant that occurs as a result of incomplete fetal gut rotation with fixation. Associated with the subhepatic cecum and appendix in this patient was a short ascending colon. Cecum and appendix normally are located further inferiorly (Figure 3&4).

Figure 4. Appendicitis with normal anatomy. Here is another patient with inflamated appendix (white arrow). Compare the level of cecum and appendix to the patient in figure 2, where both kidneys and the inferior border of liver can be observed. In this patient, one can estimate the level of L5 vertebral body by the presence of right and left common iliac arteries (black arrows) and formation of inferior vena cava (yellow arrow).

Read the following article and watch the video for more in depth anatomy of the appendix and the large intestine.
The cecum and the vermiform appendix
Large intestine

Explanations to objectives

Objectives

  • Describe the meaning and boundaries of the abdominal quadrants and regions.
  • Describe the location and significance of the hepatorenal pouch of Morison. 
  • Explain why the results of the ultrasound exam were nonspecific, what was the significance of the absence of free air under the diaphragm, and why the preliminary diagnosis was a peptic ulcer.
  • Describe the etiology of appendicitis and what “guarding” means.
  • Describe the etiology of GI anomalies relative to incomplete (malrotation) and fixation.

Abdominal regions and quadrants

For descriptive purposes the abdominal wall and the contents of the abdomen have classically been divided into quadrants (Figure 5), but for more accurate description into nine regions (Figure 5). The midsagittal plane and a horizontal plane through the umbilicus divide the abdomen into quadrants; in contrast the midaxillary, and subcostal (10th costal cartilage) and intertubercular planes are used to define the nine abdominal regions.

Figure 5. Illustration depicting the boundaries of the abdominal regions (up) and quadrants (down).

Hepatorenal recess (pouch of Morison)

The hepatorenal recess (subhepatic recess, pouch of Morison or Morison's pouch; Figure 6) is a potential space that lies between the liver and right kidney. Normally the space is empty but fluid can collect in this space in circumstances where there is excess fluid (e.g., blood from trauma or infected fluids from an inflamed viscus) in the peritoneal cavity. This fluid may be visualized in ultrasound or CT). The presence of infected fluids in the hepatorenal pouch is potentially life-threatening because these fluids can result in peritonitis and sepsis.

Figure 6. Axial CT showing the location of hepatorenal pouch of Morison (highlighted with green) between liver and right kidney

Diferential diagnostics to perforated peptic ulcer

The patient, in this case, had pain in his epigastric and right hypochondriac regions (Figure 5), and dyspepsia. These two signs and symptoms plus fluid in Morison’s pouch suggest he had a perforated stomach or duodenal ulcer in which infected fluid from the ulcer was accumulating in the pouch. A positive finding of fluid in Morison’s pouch is sensitive for an abnormality but not specific for what the abnormality is. Furthermore, a perforated peptic ulcer also typically releases air that shows up as free air under the diaphragm in a chest radiograph and it is significant that this was not the case in this patient. In this case, the fluid in Morison’s pouch originated from the inflammation of appendix, which is a very rare location for that organ. Therefore, appendicitis was presented with signs and symptoms more frequently related with a perforated peptic ulcer. However, the opposite is possible too. In other cases the fluid from a perforated peptic ulcer may go down with gravity and cause inflammation of other parts of the parietal peritoneum. If this happens in the lower right quadrant, a perforated peptic ulcer may be misdiagnosed as acute appendicitis due to the location of the pain.

Ethiology of appendicitis & Guarding

The appendix is a tubular blind pouch that is attached to the cecum at the junction of the three taenia coli. Typically it is located in the lower right quadrant, or the right lumbar region (Figures 7&8).

Figure 7. Cadaver image showing appendix in the lower right quadrant.

The literal translation of 'appendix vermiformis' would mean that it is a worm-like structure. Let's take a closer look into it again.

Figure 8. High magnification image of the appendix.

When inflamed, the patient has appendicitis. Inflammation is often caused by a fecalith (small piece of fecal matter) obstructing fluid drainage from the appendix. The location of the base of the appendix typically corresponds tot McBurney’s point on the abdominal wall, which is two-thirds of the distance between the umbilicus and the anterior superior iliac spine. Usually, pain from an inflamed appendix migrates from the umbilical region to the right iliac (inguinal) regions. This occurs as the inflamed appendix swells and makes contact with the peritoneum on the anterior abdominal wall. The initial pain in the epigastric region, which is from a visceral source, is a good example of referred pain. The pathology is in the appendix, which is located in the lower right quadrant, but the pain is felt at the anterior abdominal wall in the epigastric region. As the disease progress and involve the parietal peritoneum, the somatic pain innervation gets activated and patients feels the pain in the exact location of the pathology. Further, this lower right pain worsens with pressure and thus the patient tends to keep his abdominal muscles tense to prevent movement of the abdominal wall. This is known as guarding.

Incomplete malrotation and fixation

During normal fetal development, the three divisions of the GI tract, i.e., the foregut, midgut and hindgut, herniate anteriorly out of the abdominal cavity and then undergo a 270º counterclockwise rotation. This rotation revolves around the superior mesenteric vessels. Subsequently, the three gut divisions re-enter the abdominal cavity.

Then, parts of the rotated gut become fixed to the posterior abdominal wall. Incomplete malrotation refers to any variation of the normal rotation and fixation. Such malrotation results in various anatomical anomalies such as the one described in this case. Had this patient’s appendix not become inflamed it is likely this anatomic variant would not have caused the patient any GI problems.

Clinical Case: Subhepatic Cecum with Subhepatic Appendicitis - want to learn more about it?

Our engaging videos, interactive quizzes, in-depth articles and HD atlas are here to get you top results faster.

Sign up for your free Kenhub account today and join over 1,006,141 successful anatomy students.

“I would honestly say that Kenhub cut my study time in half.” – Read more. Kim Bengochea Kim Bengochea, Regis University, Denver

Show references

References:

  • Chong HC, Chai FY, Balakrishnan D, Asilah SMD, Adila INI, Syibrah KZ.'. Malrotated Subhepatic Caecum with Subhepatic Appendicitis: Diagnosis and Management . Case Reports in Surgery Volume 2016, Article ID 6067374, http://dx.doi.org/10.1155/2016/6067374
  • Modified by Joel A. Vilensky PhD, Carlos A. Suárez-Quian PhD, Aykut Üren, MD.

Authors:

  • Joel A. Vilensky 
  • Carlos A. Suárez-Quian
  • Aykut Üren

Layout:

  • Dimitrios Mytilinaios
  • Abdulmalek Albakkar
  • Jana Vaskovic
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