82 J Gandhara Med Dent Sci April - June 2025 : : CASE REPORT SUBHEPATIC PERFORATED APPENDICITIS COMPLICATED BY INTESTINAL OBSTRUCTION: A CASE REPORT Waseem Ullah 1 , Faseeh Muhammad 2 , Muhammad Daud 3 , Aahan Atta 4 , Muneeb Ur Rehman 5 , Fazal Ahmad 6 , Bakir Khan 7 ABSTRACT Subhepatic appendicitis is an anatomical variant of acute appendicitis that sometimes occurs secondary to mid gut malrotation or developmental abnormalities during fetal development. It represents only 0.01% of cases of appendicitis and can be misdiagnosed for other intra - abdominal conditions like acute cholecystitis or liver abscesses, resulting in delayed diagno sis. This is a case of a 30 - year - old patient with subhepatic perforated appendicitis complicated by intestinal obstruction. The patient was taken for emergency exploratory laparotomy after thorough investigations and clinical examination. Subhepatic append icitis was found intraoperatively. Appendectomy was performed under aseptic techniques. Postoperatively, the patient was stable and tolerating oral fluids. This case highlights the role of imaging and early surgical approach in managing subhepatic appendic itis. KEYWORDS: Subhepatic A ppendicitis, Perforated A ppendix, Intestinal O bstruction, Exploratory Laparotomy How to ci te this article Ullah W, Muhammad F, Daud M, Atta A, Rehman MU, Ahmad F, etal. Subhepatic Perforated Appendicitis Complicated b y Intestinal Obstruction: A Case Report . J Gandhara Med Dent Sci. 202 5 ; 12(2 ): 82-85. http://doi.org/10.3 Date of Submission: 26 - 01 - 2025 Dat e Revised: 10 - 02 - 2025 Date Acceptance: 13 - 03 - 2025 1 Post grad u ate Resident, Department of General Surgery, Lady Reading Hospital, Peshawar 3 Post grad u ate Resident, Department of General Surgery, Lady Reading Hospital, Peshawar 4 Post grad u ate Resident, De partment of General Surgery, Lady Reading Hospital, , Peshawar 5 Post grad u ate Resident, Department of General Surgery, Lady Reading Hospital, , Peshawar 6 Post grad u ate Resident, Department of General Surgery, Lady Reading Hospital, , Peshawar 7 Post grad u ate Resi dent, Department of General Surgery, Lady Reading Hospital, , Peshawar Correspondence 2 Faseeh Muhammad, Post grad u ate Resident, Department of General Surgery , Lady Reading Hospital, Peshawar +92 - 343 - 9995946 faseehdirvi@gmail.com INTRODUCTION Subhepatic appendicitis is a rare anatomical variant of acute appendicitis that represents only 0.01% of all cases. 1 This rare presentation is secondary to an unusual anatomical location of the appendix, usually due to midgut malrotation or developmental abnormalities during fetal development. The subhepatic appendix is in the inferior surface of the liver in contrast to the usual retrocecal or pelvic appendix, often leading to diagnostic confusion with acute cholecystitis or liver abscesses. 1,4 Therefore, surgeons must be aware of such variations in the anatomical location of the appendix, which is essential for early diagnosis and treatment to avoid complications such as perforation or sepsis. Subhepatic appendicitis is not uncomplicated to diagnose because clinical and imaging features are unusual. Patients with subhepatic appendicitis do not show resemblance in clini cal signs to retrocecal appendix, i.e right lower quadrant pain and tenderness at McBurney’s point. 1,2 CT and ultrasound are also useful in diagnosing subhepatic appendicitis since they provide better visualisation of the appendix and any associated pathol ogy, including fluid, abscess formation, or inflammation. 2,4 The appendix, located beneath the liver, can appear as part of a complex pattern of anatomical variants, which includes cecal malrotation and vascular malformations. The surgical procedures becom e more challenging because of these different locations, which require different surgical approaches. The preferred approach for appendix removal requires open midline incisions instead of 7762/jgmds.627
83 J Gandhara Med Dent Sci April - June 2025 gridiron incisions to ensure complete visualisation because their i mproper recognition leads to delayed treatment and increased morbidity. 1 The case report explains this unusual presentation of the appendix, which should be included in differential diagnosis for atypical abdominal pain. We aim to highlight this uncommon p resentation and its management through early imaging and surgical expertise based on previous studies. CASE PRESENTATION Our patient was a 30 - year - old male plumber with no known medical and surgical history. He has no significant socioeconomic status, fa mily history, or allergies, and he was not taking any medication. The patient presented to the Emergency Department of Lady Reading Hospital, Peshawar, with a history of three days of generalised abdominal pain with constipation and low - grade fever. The pa tient described the pain as first localised to the umbilicus and dull. The patient had three episodes of vomiting and was feeling drowsy. He never indulged in smoking or drug addiction. Initial vital signs included temperature: 39.4°C, blood pressure: 110/ 75 mmHg, heart rate: 102 beats per minute, respiratory rate: 21 breaths per minute, and oxygen saturation: 95% on room air. He was conscious, alert, and well oriented, with a Glasgow Coma Scale score of 15 and normal breathing and vesicular breath sounds. On abdominal examination, the whole abdomen was found to be tense, tender and guarded. Percussion was dull with no fluid thrill and shifting dullness. Bowel sound was faint on auscultation. Other systemic examination was unremarkable. Initial baseline inve stigations were ordered, which were within normal limits, and this included a complete blood count (CBC), total leukocyte count (TLC), liver function tests (LFTs), and serum electrolytes. Initial ultrasonography demonstrated a subhepatic appendicitis with no ascites. An x - ray of the abdomen shows multiple gas - filled loops in the small bowel. Axial computed tomography (CT) without contrast showed the appendix, a single slice below the liver and multiple air - fluid levels. The patient was administered cefopera zone, sulbactam 2g stat, metronidazole 400 mg, and one litre of Normal Saline 0.9%. Suspecting perforated appendicitis and subsequently peritonitis, it was decided to proceed with an emergency laparotomy. Figure 1: Ultrasound Image Showing a Subhepatic A ppendix with Echogenic Mesentery. Figure 2: Axial Non - Contrast Ct Scan Demonstrating an Appendix Located Single Slice below Liver, With Multiple Air Fluid Levels. Figure 3: Erect X-ray of the Abdomen Shows Multiple Gas- Filled Loops of the Small Intestine. The patient had undergone emergency laparotomy under general anesthesia and aseptic measures. A midline incision was given, and the abdomen was opened layer by layer. Significant intraoperative Subhepatic Perforated Appendicitis Complicated by Intestinal
84 J Gandhara Med Dent Sci April - June 2025 findings included a subhepatic perforated appendicitis that contai ned a fecalith adhering to the liver and widely surrounded by dense adhesions. The dense adhesions were carefully lysed, and then appendectomy was carried out, followed by the irrigation of the area using normal saline and the placement of a pelvic drain. The abdomen was closed in layers in a reverse fashion. Figure 4 : Intraoperative View of the Perforated Appendix Adherent to the Liver The patient had an uneventful postoperative course. The pelvic drain was removed on the second postoperative day with n o fluid collection. He was tolerating oral liquid and solid diets. The patient was discharged on the third postoperative day, stable with a resolved fever. A 10 - day follow - up was found to have a clean surgical wound, an uneventful removal of sutures, compl ete patient mobilisation, and continued clinical stability. DISCUSSION Subhepatic perforating appendicitis is a rare disease, representing 0.08% of total acute appendicitis.6 This atypical presentation is due to abnormalities in cecal descent or midgut m alrotation during embryogenesis. The subhepatic position of the appendix can be misdiagnosed for different abdominal pathologies like cholecystitis, liver abscess, and pancreatitis, causing delayed diagnosis and a higher rate of complications in the form o f perforation and peritonitis. 4,6 Early diagnosis becomes essential because subhepatic appendicitis shows different signs and symptoms than acute appendicitis. The typical signs of retrocaecal appendicitis include right lower quadrant pain and McBurney’s p oint tenderness, while subhepatic appendicitis often manifests as diffuse or upper abdominal pain.3 The patient’s initial presentation of umbilical pain spreading throughout the abdomen strengthened the physician's diagnostic suspicion. 6 Detecting anatomic al abnormalities and concurrent complications such as perforation, abscesses, or adhesions requires imaging modalities, including computed tomography (CT) and ultrasonography. CT imaging is the most accurate diagnostic tool for subhepatic appendicitis and its unusual The surgical approach for subhepatic perforated appendicitis differs from standard laparoscopic appendectomy because it serves as the gold standard treatment for uncomplicated ic appendicitis requires open surgery because of dense adhesions and proximity to vital structures such as the A midline laparotomy approach allowed proper visualisation and delicate l while 5 Managing complex anatomical structures requires personalised surgical approaches that help minimize Perforated appendicitis delayed It is reported that 42% of patients abdominal abscesses (1.6%) and longer stays in the hospital are also frequent.5 Mortality rates in perforated so in 4 Prompt diagnosis and early operation are necessary to prevent these outcomes. Moreover, perioperative antibiotics have been documented to lower complication rates, stressing the value of a sciplinary treatment process for perforated appendicitis.7 This case also points out the general appendix. The unusual anatomical variations of subhepatic appendicitis are to be kept in mind in case of Clinical suspicion, along with thorough Imaging and surgical readiness can significantly improve the diagnostic rate and treatment In addition, reporting such cases helps the medical fraternity understand such unusual manifestations. 2,4 appendicitis. 6 The surgical approach for subhepat liver and hepatic flexure. 3 adhesive release for a secure appendix remova providing thorough abdominal cavity irrigation. postoperative complications. 6 will increase the morbidity, particularly in presentation. 5 develop surgical site infections, while intra - appendicitis can be as high as 4.8%, more complicated or severe cases or with co - morbidities. multidi significance of the anatomical variations of the unexp lained abdominal pain. 6 results. 7 pres entations and guides future clinical practice. 1,7 CONCLUSIONS The anatomical variations in subhepatic perforated appendicitis pose both diagnostic and therapeutic challenges. This case illustrates the management of this relatively uncommon condition by u sing advanced imaging, maintaining high clinical suspicion, and tailoring surgical strategies for managing this rare condition. Raising awareness and integrating knowledge from similar cases into clinical guidelines can improve diagnostic accuracy and opti mise patient outcomes in such complex presentations. CONFLICT OF INTEREST: None FUNDING SOURCES: None Subhepatic Perforated Appendicitis Complicated by Intestinal
85 J Gandhara Med Dent Sci April - June 2025 LICENSE: JGMDS publishes its articles under a Creative Commons Attribution Non-Commercial Share-Alike license ( CC-BY-NC-SA 4.0 ). COPYRIGHTS: Authors retain the rights without any restrictions to freely download, print, share and disseminate the article for any lawful purpose.It includes scholarlynetworks such as Research Gate, Google Scholar, LinkedIn, Academia.edu, Twitter, and other academic or professional networking sites. 1. Hakim M, Mostafa R, Al Shehri M, Sharawy S. Surgical management of subhepatic perforated appendicitis: A case report. J Med Case Rep. 2 020;14:151. Available from: https://doi.org/10.1186/s13256 - 020 - 02499 - 2. 2. White H, Laykova AS, O'Dowd B, Wasfie T. Unusual presentation of perforated acute appendicitis: A case report. Am J Case Rep. 2022;23:e935405. Available from: https://doi.org/10.12 659/AJCR.935405. 3. McGuin C, Pillay Y. An unusual case report of a subhepatic appendix and an interlobar hepatic bridge in a patient with acute cholecystitis. J Surg Case Rep. 2023;2023(4):rjad185. Available from: https://doi.org/10.1093/jscr/rjad185. 4. Afroze M KH, Muralidharan S, Shanmugam A, Khan AW, Bhowmik S. Two cases of positional variation of the cecum and appendix with a vascular anomaly: A diagnostic dilemma. Cureus. 2022;14(7):e27091. Available from: https://doi.org/10.7759/cureus.27091. 5. Potey K, Kandi A, Jadhav S, Gowda V. Study of outcomes of perforated appendicitis in adults: A prospective cohort study. Ann Med Surg (Lond). 2023;85:694 - 700. Available from: https://doi.org/10.1097/MS9.0000000000000277. 6. Teferi DA, Gebru S, Kassa AT, A bebe HA, Yehualawork SF, Teferi WA. Acute appendicitis in a patient with sub - hepatic, sub - serosal, and retroperitoneal location: An intraoperative management challenge. Int J Surg Case Rep. 2024;125:110540. Available from: https://doi.org/10.1016/j.ijscr.2 024.110540. 7. Ahmed A, Feroz SH, Dominic JL, Muralidharan A, Thirunavukarasu P. Is emergency appendicectomy better than elective appendicectomy for the treatment of appendiceal phlegmon?: A review. Cureus. 2020;12(12):e12045. Available from: https://doi. org/10.7759/cureus.12045. CONTRIBUTORS 1. Waseem Ullah - Concept & Design; Drafting Manuscript 2. Faseeh Muhammad - Data Acquisition 3. Muhammad Daud – Data Analysis/Interpretation 4 . Aahan Atta – Drafting Manuscript 5. Muneeb Ur Rehman - Supervis ion 6 . Fazal Ahmad - Drafting Manuscript 7. Bakir Khan - Drafting Manuscript REFERENCES Subhepatic Perforated Appendicitis Complicated by Intestinal