Perforated Subhepatic Appendicitis Mimicking Hepatobiliary Pathology: A Case Report and Narrative Literature Review.

Subhepatic appendicitis is a particularly rare anatomical variant presenting with atypical right upper quadrant (RUQ) pain mimicking hepatobiliary pathology. This mimicry frequently leads to diagnostic delay and subsequent increased risk of complications. A 41-year-old man presented to the Emergency Department with acute RUQ pain, radiating to the back and shoulder, accompanied by constitutional and gastrointestinal symptoms. RUQ ultrasound visualized no gallbladder abnormalities; subsequent CT scan revealed a dilated appendix with a rounded tip and possible presence of an abscess. Initial surgical intervention was attempted laparoscopically; however, conversion to an open appendectomy was required due to the complex anatomy, including a subhepatic cecum adhered to the retroperitoneum, and intraoperative bleeding. The cecal caput was divided to preserve the ileocecal valve. Pathological assessment was consistent with appendicitis with rupture due to postinflammatory changes. The postoperative course was largely uncomplicated with transient ileus, and the patient was discharged on postoperative day 3. Although subhepatic appendicitis is rare, it should be considered when patients present with RUQ pain and hepatobiliary assessment proves negative. In case of a nondiagnostic ultrasound, CT imaging should be employed early in the diagnostic exploration. As conversion from a laparoscopic to an open approach may be warranted in these cases, the surgical team should be vigilant when encountering such a patient.