True Subhepatic Appendicitis: Diagnostic Challenges and Surgical Implications

Abstract

Acute appendicitis is a common surgical emergency; however, atypical anatomical positions of the vermiform appendix can significantly alter clinical presentation and complicate diagnosis. Subhepatic appendicitis is a rare variant, often mimicking hepatobiliary pathology and leading to diagnostic delay. We report the case of a 33-year-old female with no significant medical history who presented with a 48-hour history of acute right hypochondrium pain associated with fever and anorexia. Physical examination revealed localised tenderness without signs of generalised peritonitis. Laboratory investigations showed significant inflammatory markers, while the Alvarado score was low (4/10). Abdominal ultrasonography was inconclusive. Contrast-enhanced computed tomography revealed a retrocecal appendix in a true subhepatic position with surrounding inflammatory changes, consistent with acute subhepatic appendicitis. Emergency laparoscopic exploration confirmed a high-lying cecum and subhepatic appendix. A retrograde laparoscopic appendectomy was successfully performed. The postoperative course was uneventful, and the patient was discharged on postoperative day one. Histopathological examination confirmed acute non-specific pan-appendicitis. Subhepatic appendicitis is a rare but important differential diagnosis in patients presenting with right hypochondrium pain. This case highlights the limitations of clinical scoring systems in atypical appendiceal locations and emphasises the essential role of computed tomography in diagnosis. Laparoscopic management with adapted port placement and retrograde dissection ensures safe and effective treatment in true subhepatic appendicitis.