Subhepatic Appendicitis With Appendicular Diverticulitis: A Rare Combination for Acute Abdomen

Subhepatic appendicitis is an unusual presentation of acute appendicitis (AA). Similarly, another uncommon condition that resembles AA is appendiceal diverticulitis (AD), which is a rare form of vermiform appendix pathology. It is exceedingly uncommon for the two to occur simultaneously. We present the case of a 41-year-old male presented with a one-day history of sudden onset of right iliac fossa (RIF) pain associated with a two-day history of nausea and fevers. The only notable lab finding was elevated C-reactive protein (CRP). Clinical examination revealed right abdominal and renal angle tenderness, with RIF rebound and guarding. Computed tomography (CT) concluded acute uncomplicated appendicitis with a subhepatic appendix and he was planned for an emergent laparoscopic appendicectomy. Exposure of the retrocaecal appendix with the caecum in the right loin posed a challenging laparoscopy. The appendix was found to be adherent to the duodenum, right kidney, and transverse colon, and the decision was made to convert to laparotomy to establish safe mobilisation from the duodenum. The appendix was resected in two parts and the histopathology revealed an appendiceal diverticulum with subserosal abscess formation. The subhepatic position of the cecum and appendix is a result of foetal gut malrotation. There is no standard approach for the best course of treatment. The laparotomy conversion gave us better tactile input and direct access to the appendix. Our goal is to educate readers on how to manage an unusual presentation of AA.