Ibrahim 

Mamadou et al. J Med Case Reports (2021) 15:288

https://doi.org/10.1186/s13256-021-02883-6

CASE REPORT Open Access

Subhepatic appendix: an ectopic

topography not to be disregarded: a case report
Abdoul Kadir Ibrahim Mamadou1*  , Souleymane Mounkaila2, Nouhou Hama Aghali3,
Mahaman Laouali Harouna Amadou4 and Ousseini Adakal5 

Abstract 
Introduction:  Subhepatic appendix is most often due to an anomaly of rotation of the primary intestine occurring
during embryogenesis. This ectopic topography associated with advanced age can be a serious diagnosis problem at
the stage of appendicitis or appendicular peritonitis.
Case presentation:  We report the case of a 60-year-old melanoderm man, with a history of urinary pathology and
peptic ulcer, referred from a health district for abdominal pain of the right hypochondrium evolving for about 5 days,
secondarily generalized, in whom we suspected peritonitis, the etiology of which remains to be determined. During
the surgical intervention, after preoperative resuscitations measures, a phlegmonous perforated appendix was found
under the liver. No postoperative complication was noted, and he was discharged home 8 days after his operation.
Conclusion:  Subhepatic appendicular peritonitis occurring in an elderly patient poses enormous diagnostic prob-
lems. When faced with right upper quadrant pain, considering acute ectopic appendicitis would significantly reduce
complications.
Keywords:  Peritonitis, Subhepatic appendix, Embryogenesis, Case report

Introduction developing countries, to think about this diagnosis when

Acute appendicitis, the most frequent emergency in faced with a similar symptomatology. This may reduce
digestive surgery, is a well-known pathology in children diagnostic errors, thus helping to save patients’ lives.
and young adults. Its diagnosis presents some difficul-
ties in the elderly. Appendicitis is a source of contro- Case report
versy between radiologists and clinicians [1, 2]. Ectopic We report the case of a 60-year-old melanoderm man,
topographies pose serious diagnostic problems, delay- with a history of urinary pathology not documented
ing adequate surgical management. We report the clini- 20 years ago and a peptic ulcer that was also undocu-
cal case of subhepatic appendicular peritonitis in a mented. No significant family history was reported. He
60-year-old patient. This case is particularly interesting was referred from Keita Health District for abdominal
considering, on the one hand, the ectopic topography pain that was first localized in the right hypochondrium
of the appendix, but also the age of the beginning of the before becoming generalized, with fever and vomiting,
pathology. Another important fact is that this article without stopping transit for about 5 days.
draws the attention of medical practitioners, especially in On admission, the patient had good general condition
as well as well-colored conjunctiva and mucous mem-
branes, with Glasgow score  15, temperature 37.3  °C,
*Correspondence: kader.ibrahim@yahoo.fr blood pressure: 120/80  mm  Hg, heart rate 68  beats per
1
Department of Medicine and Medical Specialties, Regional Hospital
Center of Tahoua, Tahoua, Niger minute, respiratory rate 34 cycles per minute, and oxygen
Full list of author information is available at the end of the article

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Ibrahim Mamadou et al. J Med Case Reports (2021) 15:288 Page 2 of 4

saturation 99%. Physical examination revealed a soft but the ileocecal junction (Figs. 2 and 3). An appendectomy,
sensitive abdomen with a screaming umbilicus. a hemostasis, and a promontofixation of the rectum and
Proctological examination revealed a huge anal peritoneal toilet were subsequently performed, followed
prolapse. by installation of a drain in the Douglas cul-de-sac. No
Laboratory investigations showed that he had a white postoperative complication was noted, and he was dis-
blood cell count of 28,100/mm3 predominantly granu- charged home 8  days after his operation with antibiotic
locytic; anemia at 10.7  g/dl, normocytic, normochro- therapy and analgesic.
mic; hyperplaquettosis at 528,000/mm3; Rhesus blood
grouping O negative; normal uremia at 0.23 g/dl; normal Discussion
serum creatinine at 10.13 mg/l; and normal blood sugar Several works of literature admitted that “the true inci-
at 1.07 g/l. dence of acute appendicitis in most developing African
An emergency abdominal ultrasound does not objec- countries is largely unknown due to poor medical record-
tively detect the presence of the cecum and appendix in keeping and unreliable population census” [3].
the iliac fossa. However, it does objectively determine the Appendicitis is a predominantly male condition health
normality of the gallbladder. We do not have a computed issue, and it occurs more often in young people than in
tomography (CT) scan in the regional hospital center to the elderly. Elsewhere, there has been a significant sea-
further support the diagnosis. sonal effect, with an increased frequency in summer [4,
All in all, the diagnosis of peritonitis seemed obvious, 5].
even though the etiology remains to be determined. The location of the appendix in the subhepatic position
After an intensive preoperative reanimation, a median has two origins—an exceptional one called subhepatic
laparotomy was performed. The exploration showed an appendix, of which few cases have been reported in the
acute generalized peritonitis with pus (Fig. 1), distension literature so far, and a more common one corresponding
of the colonic frame with a left dolichocolon, false mem- to a retrocecal appendix ascended below the liver. The
branes, and a phlegmonous subhepatic appendix perfo- exception is due to a rotation abnormality of the primary
rated. It measures up to 10 cm and is located 3 cm from intestine occurring during the 11th week of embryonic

Fig. 1  Perioperative view of subhepatic appendix Fig. 2  Perforated appendix under the liver
 Ibrahim Mamadou et al. J Med Case Reports (2021) 15:288 Page 3 of 4

and indispensable in complicated forms (especially

appendicular perforations) and for most ectopic forms [9,
10].
A meta-analysis suggests that although antibiotics
may be used as primary treatment for some patients sus-
pected of having uncomplicated appendicitis, they are
unlikely to supplant appendectomy at this time. Selec-
tion bias and the shift to surgery in the three randomized
controlled trials suggest that appendectomy is the gold
standard therapy for acute appendicitis [11].
Acute appendicitis in the elderly is always associated
with significant morbidity. Preexisting severe comorbidi-
ties are a major contributing factor to mortality in these
patients. The morbidity in one series was exclusively pari-
etal suppuration [1, 12].
In developing countries, due to limited means of inves-
tigation and precarious health facilities, similar patholo-
gies can go unnoticed, unfortunately affecting the vital
prognosis. It is imperative to equip our centers with high-
performance imaging resources to make these types of
diagnoses at the preoperative stage.

Conclusion
Ectopic appendicular peritonitis in old age poses enor-
mous diagnostic difficulties. A rapid positive diagnosis
Fig. 3  Appendix after surgical excision combined with appropriate management would reduce
the high morbidity and mortality associated with this
condition.
development and placing the cecum in the upper quad- Acknowledgements
rant [6]. Not applicable.
Diagnosis of appendicitis has relatively low accu-
Authors’ contributions
racy in the elderly. Despite the infrequent occurrence of AKIM, corresponding author, initiated the work, and wrote the discussion
appendicitis, the rate of perforation is always unfavora- and the rest of the work. SM, the surgeon, provided the attached images
ble. Postoperative morbidity and mortality are too high. and wrote the observation. NHA, MLAH, and OA, each according to their
competence, contributed to the improvement of the manuscript. All the
Advanced age adversely affects the clinical diagnosis, the authors contributed to the writing of this manuscript, and all authors read and
stage of the disease, and patient outcomes. Perforated approved the final manuscript.
appendicitis and septic progression are the main cause of
Funding
poor outcomes [7, 8]. This research received no specific grant from any funding agency in the pub-
The subhepatic position of the appendix results in lic, commercial, or not-for-profit sectors.
unusual, nonspecific clinical symptoms, delaying diag-
Availability of data and materials
nosis to the stage of appendicular rupture [6]. There are Data sharing not applicable to this article as no datasets were generated or
many positional variations of the appendix in relation to analyzed during the current study.
the cecum: mediocecal, the most frequent, retrocecal, in
contact with the right iliac psoas muscle, anterior or pos- Declarations
terior subcecal, prececal, and anterior or posterior ileoce-
Ethics approval and consent to participate
cal. Similarly, positional variations of the cecum or length Not applicable.
of the appendix will determine subhepatic, pre- or retro-
colonic appendicitis and pelvic appendicitis [9]. Consent for publication
Written informed consent was obtained from the patient for publication of
An x-ray of the abdomen without preparation is an this case report and any accompanying images. A copy of the written consent
insufficient or even useless examination in the diagnosis is available for review by the Editor-in-Chief of this journal.
of acute appendicitis. Ultrasound is often sufficient for
Competing interests
a positive diagnosis of acute appendicitis, especially in The authors declare that they have no competing interests.
young subjects. Computed tomography scan is necessary
Ibrahim Mamadou et al. J Med Case Reports (2021) 15:288 Page 4 of 4

Author details 2019;1(6):202-211. http://​www.​thewo​rldwi​demed​icine.​com/​artic​les/​pdf/​

1
 Department of Medicine and Medical Specialties, Regional Hospital Center Alegb​eleye​2019-1-​6-​Origi​nal%​20art​icle.​pdf.
of Tahoua, Tahoua, Niger. 2 Department of Surgery and Surgical Specialties, 6. Hornoy B, Char G, Marotel M, Lasry JL. Appendicite en position sous-
Regional Hospital Center of Tahoua, Tahoua, Niger. 3 Department of Biology, hépatique. J Radiol. 1997;78(5):388-392. www.​emcon​sulte.​com/​showa​
Regional Hospital Center of Maradi, Faculty of Health Sciences of the Univer- rticl​efile/​122328/​index.​pdf.
sity of Maradi, Maradi, Niger. 4 Department of Infectiology, Regional Hospital 7. Gürleyik G, Gürleyik E. Age-related clinical features in older patients with
Center of Maradi, Faculty of Health Sciences of the University of Maradi, acute appendicitis. Eur J Emerg Med. 2003;10(3):200–3.
Maradi, Niger. 5 Department of Surgery, Regional Hospital Center of Maradi, 8. Pokharel N, Sapkota P, Kc B, Rimal S, Thapa S, Shakya R. Acute appen-
Faculty of Health Sciences of the University of Maradi, Maradi, Niger. dicitis in elderly patients : a challenge for surgeons. Nepal Med Coll J.
2011;13(4):285–8.
Received: 25 May 2020 Accepted: 26 April 2021 9. Mathias J, Bruot O, Ganne P-A, Laurent V, Regent D. Appendicite EMC
(Elsevier Masson SAS, Paris), Radiodiagnostic- Appareil digestif, 33-472-G-
10,2008. http://​oncle​paul.​net/​wp-​conte​nt/​uploa​ds/​2011/​07/​appen​dicit​
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