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Abstract
Sub hepatic cecum and appendix is a rare anatomical condition with a reported incidence of 0.08%. This results from the developmental incomplete rotation or malrotation of the midgut and arrested descent of the caecum. In this position, if there occurs an inflammation, the resulting right upper abdominal pain is mistaken for acute cholecystitis, liver abscess, or perforated duodenal ulcer. Moreover, this may be missed on imaging modalities. This necessitates clinical suspicion of subhepatic appendicitis in case of undiagnosed right upper abdominal pain. Herein we report a case of caecum and appendix encountered in the right hypochondrium beneath the liver during routine anatomical dissection of a cadaver.
Caecum and appendix are the early parts of the large intestine and are situated in the lower part of the abdomen on the right side, corresponding to the iliac fossa. The appendix is a narrow muscular tube varying in length between 3 inches and 5 inches, the base of which is attached to the posterior wall of caecum just below the ileo-caecal junction.[1] The most common position of the appendix is retrocecal in position in the right iliac fossa. Acute appendicitis is not uncommon during life, normally diagnosed with a high index of clinical suspicion followed by laboratory and imaging modalities. But, when the caecum and appendix are situated in a location other than the usual right iliac fossa, the diagnosis of acute appendicitis becomes challenging and erroneous.[2] Delay in diagnosis or wrong diagnosis because of an abnormally located appendix when inflamed may lead to delay in recognizing the appendicitis, which may result in the perforation of the appendix, a surgical emergency.[3] King in 1975 was the first one to report a case of abnormally located appendicitis.[4] Ideally, the right iliac fossa is the place where the terminal segment of the ileum joins the caecum.[5] However, when the caecum is in subhepatic region, the terminal part of the ileum passes through the right iliac fossa and joins the caecum. Herein we report a case of a subhepatic caecum with an appendix encountered during routine anatomical dissection and discuss the complication resulting from such anomaly.
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References
- Snell RS. Clinical anatomy by regions. Philadelphia: Lippincott Williams & Wilkins 2012.
- Schumpelick V, Dreuw B, Ophoff K, et al. Appendix and cecum: embryology, anatomy, and surgical applications. Surg Clin North Am 2000;80(1):295-318.
- Kulvatunyou N, Schein M. Perforated subhepatic appendicitis in the laparoscopic era. Surg Endosc 2001;15(7):769.
- King A. Subhepatic appendicitis. AMA Arch Surg 1955;71(2):265-7.
- Standring S. Gray's anatomy: the anatomical basis of clinical practice. 39th edn. New York: Elsevier Churchill Livingstone 2005.
- Spence JR, Lauf R, Shroyer NF. Vertebrate intestinal endoderm development. Dev Dyn 2011;240(3):501-20.
- Applegate KE, Anderson JM, Klatte EC. Intestinal malrotation in children: a problem-solving approach to the upper gastrointestinal series. Radiographics 2006;26:1485-500.
- Awapittaya B, Pattana-Arun J, Tansatit T, et al. New concept of ileocecal junction: intussusception of the terminal ileum into the cecum. World J Gastroenterol 2007;13(20):2855-7.
- Deshmukh S, Verde F, Johnson PT, et al. Anatomical variants and pathologies of the vermix. Emerg Radiol 2014;21(5):543-52.
References
Snell RS. Clinical anatomy by regions. Philadelphia: Lippincott Williams & Wilkins 2012.
Schumpelick V, Dreuw B, Ophoff K, et al. Appendix and cecum: embryology, anatomy, and surgical applications. Surg Clin North Am 2000;80(1):295-318.
Kulvatunyou N, Schein M. Perforated subhepatic appendicitis in the laparoscopic era. Surg Endosc 2001;15(7):769.
King A. Subhepatic appendicitis. AMA Arch Surg 1955;71(2):265-7.
Standring S. Gray's anatomy: the anatomical basis of clinical practice. 39th edn. New York: Elsevier Churchill Livingstone 2005.
Spence JR, Lauf R, Shroyer NF. Vertebrate intestinal endoderm development. Dev Dyn 2011;240(3):501-20.
Applegate KE, Anderson JM, Klatte EC. Intestinal malrotation in children: a problem-solving approach to the upper gastrointestinal series. Radiographics 2006;26:1485-500.
Awapittaya B, Pattana-Arun J, Tansatit T, et al. New concept of ileocecal junction: intussusception of the terminal ileum into the cecum. World J Gastroenterol 2007;13(20):2855-7.
Deshmukh S, Verde F, Johnson PT, et al. Anatomical variants and pathologies of the vermix. Emerg Radiol 2014;21(5):543-52.