Subhepatic Caecum and Appendix - A Case Report

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.