Christian Nehme, MD1, Dipen Patel, MD, MBA1, Sami Ghazaleh, MD2, Sehrish Malik, MD2, Azizullah Beran, MD2, Wasef Sayeh, MD1, Justin Chuang, MD1, Jordan Burlen, MD1, Thomas Sodeman, MD1 1University of Toledo, Toledo, OH; 2University of Toledo Medical Center, Toledo, OH
Introduction: The differential diagnosis for a patient presenting with right upper quadrant pain is broad, and it commonly includes hepatobiliary pathology. Appendicitis in the subhepatic region is a rare condition that can present as acute cholecystitis. We present a case of acute appendicitis, not diagnosed until surgery, presenting as right upper quadrant pain and causing inflammation of the gall bladder.
Case Description/Methods: A 35-year-old female with no significant past medical history presented to the hospital with constant, severe, and sharp right upper quadrant pain of one day duration. This was associated with nausea and chills. She reported no vomiting or similar pain in the past.
On presentation, patient’s vital signs were significant for a heart rate of 55 beats/min and a blood pressure of 88/43 mm/Hg. She was afebrile. Physical exam revealed right upper quadrant abdominal tenderness with no guarding or rebound tenderness. Labs showed a white blood cell count of 12.1 x 109/L. Liver function tests were within normal limits. CT abdomen and pelvis showed abnormal appearance of the liver diffusely, suggesting hepatocellular disease. Ultrasound of the abdomen revealed heterogeneously thickened gallbladder wall which might represent acute cholecystitis. HIDA scan showed no evidence of acute cholecystitis though gallbladder ejection fraction was at 0 percent suggesting biliary dyskinesia.
During her hospital stay, patient was then taken to the operating room for presumed cholecystitis. During the surgery, an acutely inflamed appendix was identified in the right upper quadrant adjacent to the gallbladder. There was gallbladder wall edema and mild inflammation. Purulent fluid was noted in the peritoneal cavity. Laparoscopic appendectomy and cholecystectomy were performed with eventual improvement in patient’s symptoms.
Discussion: Inflammation of a subhepatic appendix is rare, and it accounts for only 0.09 percent of all appendicitis cases. During embryonic development, failure of descent of the cecum can result in a subhepatic position of the appendix. This abnormal position makes it very challenging to diagnose appendicitis. In this patient, the acutely inflamed appendix adjacent to the gallbladder might have caused inflammation in the gallbladder wall resulting in concurrent cholecystitis. Concurrent acute appendicitis and cholecystitis is rare, but it should be considered when patients present with right upper quadrant paint.
Figure: Figure 1: CT abdomen and pelvis: abnormal appearance of the liver diffusely suggesting hepatocellular disease
Disclosures: Christian Nehme indicated no relevant financial relationships. Dipen Patel indicated no relevant financial relationships. Sami Ghazaleh indicated no relevant financial relationships. Sehrish Malik indicated no relevant financial relationships. Azizullah Beran indicated no relevant financial relationships. Wasef Sayeh indicated no relevant financial relationships. Justin Chuang indicated no relevant financial relationships. Jordan Burlen indicated no relevant financial relationships. Thomas Sodeman indicated no relevant financial relationships.
Christian Nehme, MD1, Dipen Patel, MD, MBA1, Sami Ghazaleh, MD2, Sehrish Malik, MD2, Azizullah Beran, MD2, Wasef Sayeh, MD1, Justin Chuang, MD1, Jordan Burlen, MD1, Thomas Sodeman, MD1. P1136 - Concurrent Acute Appendicitis and Cholecystitis in a Patient with Right Upper Quadrant Abdominal Pain, ACG 2021 Annual Scientific Meeting Abstracts. Las Vegas, Nevada: American College of Gastroenterology.
