Sub-hepatic Caecum with Extra-pelvic Looped Sigmoid Colon: An Embryological and Clinical Perspective

Introduction: We encountered variation in the placementof large intestine in abdominal cavity of a 76-years-old malecadaver during dissection of abdominal cavity. The workwas performed in Department of Anatomy during routineMBBS teaching sessions. The aim of this paper is to reportco-existence of error of mid-gut development and alongwith variant topo-morphology of sigmoid colon in the samecadaver.Case Report: Sub-hepatic caecum with high riding vermiformappendix with absent ascending colon was seen on the rightside of abdominal cavity. Concomitantly on the left side of theabdominal cavity dilated, looped sigmoid colon occupied theleft hypochondrium, left lumbar region and left iliac fossa. Wereport these findings along with the embryological basis andclinical significance.Conclusion: An insight about the errors in development ofmid-gut resulting into the variant topography of caecum willfacilitate surgeons and radiologists in prompt diagnosis andquick modification of the protocol during invasive procedures.

Undescended cecum with accessory right colic artery: a rare case report / 대한해부학회지

Midgut malrotation and incomplete rotation are common causes of neonatal intestinal obstruction. At end of 10 week of intrauterine life, cecum will be placed in subhepatic region temporarily and descends to right lower quadrant by eleventh week. Arrest of cecum in subhepatic region or undescended cecum is a rare congenital anomaly of mid gut. Usually, it remains asymptomatic and is diagnosed incidentally. If any pathology occurs in anomalous part, like appendicitis then the diagnosis and treatment will be challenging in all age groups. Variation in blood supply have also been reported with anomalies leading to iatrogenic injuries during colonoscopy and surgeries. Lack of knowledge of these rare variations may lead to delayed diagnosis of appendicitis leading to perforation and surgical emergencies. In the present case, we describe an undescended cecum and its associated variation in branching pattern of superior mesenteric artery.

A Case of Sub Hepatic Perforated Appendicitis Presented as Multiple Gas Containing Subcapsular Hepatic Abscesses.

Appendicitis is the most common acute surgical condition of the abdomen. The diagnosis of acute appendicitis can often be made clinically. When the appendix is situated in an abnormal position, the diagnosis of acute appendicitis becomes difficult. Delayed diagnosis or misdiagnosis of subhepatic appendicitis might lead to perforations of the appendix, which is a clinical emergency. Liver abscess as a complication of appendicitis was first described in 1898 by Dieulafoy. The majority of pyogenic liver abscesses are caused by infection originating in the biliary or intestinal tracts. Pyogenic liver abscess is a rare complication of acute appendicitis. Multiple pyogenic liver abscesses are not frequently reported in the literature, but the overall mortality is high, if left with no treatment or not treated early. We have reported a case of subhepatic perforated appendix presented with multiple subcapsular liver abscesses.

Sessile ileum, subhepatic cecum, and uncinate appendix that might lead to a diagnostic dilemma / 대한해부학회지

The subhepatic position of the cecum and appendix is a result of embryological reasons. Subhepatic appendicitis can cause diagnostic dilemmas. During the dissection of an adult male cadaver aged approximately 70 years, the subhepatic position of the cecum and appendix was noted. The appendix made a "U"-shaped bend and its tip was located in the paracolic position. The cecum had appendices epiploicae, and the terminal part of the ileum was retroperitoneal and had ascended vertically to the cecum from the right iliac fossa. Functionally, the sessile part of the ileum might restrict its peristaltic movements. The abnormal position of the terminal ileum might be mistaken for an ascending colon during laparoscopic surgery. The subhepatic position of the cecum and appendix might cause confusion in the diagnosis of acute appendicitis because the tenderness in such cases is not located at the McBurney's point.

Abnormal Position of Vermiform Appendix in a Macrosomatic Infant.

In the present paper, a rare anomalyof thevermiform appendix is being reportedin a macrosomatic infant. Earlier some researchers had reported subhepatic appendix. Here we report subhepatic vermiform appendix associated with other anomalies like retroperitoneal ilium, intraperitoneal ascending colon and maldescendant cecum thathadnotreported. Further, ontogenic explanation of the anomalies is discussed in detail.

Apendicitis subhepática con absceso subdiafragmático en paciente pediátrico sin malrotación intestinal: informe de un caso / Subhepatic appendicitis with subdiaphragmatic abscess in a pediatric patient without intestinal malrotation: case report

Introducción: Los cuadros de apendicitis aguda subhepática en niños son raros y no siempre se acompañan de malrotación intestinal, lo que dificulta el diagnóstico y manejo temprano. Caso clínico: Niño de 10 años de edad, con padecimiento de cinco días de evolución caracterizado por evacuaciones diarreicas, tratado con antibióticos. Posteriormente presentó vómito, dolor abdominal tipo cólico y fiebre de 39 °C. El abdomen se encontró blando y depresible, con escaso dolor en flanco derecho. El ultrasonido y la tomografía mostraron imagen compatible con absceso subdiafragmático. Se manejó con drenaje externo. Al no obtener respuesta se realizó laparotomía exploradora, encontrando apéndice inflamada, de 10 cm de longitud, en posición ascendente sobre la corredera parietocólica derecha y perforación del extremo distal a nivel subhepático. El paciente evolucionó con sepsis abdominal y choque séptico, requiriendo nueva intervención quirúrgica para drenaje de líquido serohemático. A los 40 días el paciente fue dado de alta. Conclusiones: La consideración anatómica del apéndice es importante, por las múltiples presentaciones clínicas, de las cuales 30 % son atípicas y el diagnóstico se enmascara ocasionando complicaciones como perforación y abscesos. Los casos de apendicitis aguda de localización subhepática son raros y por lo general se asocian a malrotación del intestino. El retraso del tratamiento relacionado con el cuadro atípico, ocasionado por la posición poco habitual del apéndice, implica estancia hospitalaria más prolongada y riesgo de incrementar la morbilidad y mortalidad.

BACKGROUND: Acute subhepatic appendicitis in children is an uncommon presentation. It is usually associated with intestinal malrotation. When these conditions are met, accurate diagnosis and early management decisions are delayed. CLINICAL CASE: We present the case of a 10-year-old male who had diarrhea without mucus or blood for 5 days. He was treated with antibiotics. Afterwards, he presented with vomiting, abdominal pain, and fever. Physical examination of the abdomen demonstrated a soft and depressible mass and pain in the lower right abdomen. Abdominal ultrasound and tomography reported image of subdiaphragmatic abscess. Percutaneous puncture and drainage were performed without results. Exploratory laparotomy was then performed, revealing a subhepatic perforation of the appendix. The patient evolved with abdominal sepsis and septic shock, resulting in a new surgical intervention for drainage of serohematic fluid. The patient improved and was discharged on day 40. DISCUSSION: It is very important to consider the position of the anatomic appendix during appendicitis because it contributes to the various clinical symptoms, of which 30% are atypical. Diagnosis is masked, leading to complications such as perforations and/or abscesses that extend the hospital stay. CONCLUSIONS: Acute subhepatic appendicitis in children is an uncommon presentation. It is usually associated with intestinal malrotation. Delay in treatment due to atypical symptoms caused by the abnormal position of the appendix conditioned complications that implied a prolonged hospital stay, with the risk of increasing morbidity and mortality of the patient.

Results of Subhepatic Fluid Collection after Cholecystectomy; A Serial Sonographic Study

A prospective serial ultrasonographic study was conducted to assess the incidence of subhepatic fluid collection in 130 elective cholecystectomy patients with and without surgical drains. Fluid collection was observed in 33(25.4%) of a total of 130 cases, comprising 16 of 60 cases (26.7%) in the drained group and 17 of 70 cases (24.3%) in the undrained group. This difference was not statistically significant (P > 0.05). At the time of the initial, second, and final serial scans, fluid collection was seen in 22.3% (29/130), 10%(13/30) and 1.5% (2/130) of the cases, respectively. There was no bile leakage among the patient receiving surgical drains, nor did fluid collection continue for more than 2 weeks that manifested clinical symptoms. These results indicate that drainage after uncomplicated elective cholecystectomy is unnecessary, and that the timing of ultrasonographic studies is one of the critical factors in determining the incidence of postcholecystectomy subhepatic fluid collections.