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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.

  1. Case description
  2. Anatomical considerations
  3. Explanations to objectives
    1. Objectives
    2. Abdominal regions and quadrants
    3. Hepatorenal recess (pouch of Morison)
    4. Diferential diagnostics to perforated peptic ulcer
    5. Etiology of appendicitis & guarding
    6. Incomplete malrotation and fixation
  4. Sources
+ Show all

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).

Check the following learning materials for more in depth anatomy of the appendix and the large intestine.

Clinical case: Subhepatic cecum with subhepatic appendicitis: want to learn more about it?

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