Pediatric subhepatic appendicitis with elevated lipase

  • Scott A. McAninch
    Corresponding author at: Scott and White Medical Center - Temple, Department of Emergency Medicine, 2401 South 31st Street, Temple, Texas 76508, United States of America.
    Baylor Scott and White Health, Central Region, Department of Emergency Medicine, Texas A&M Health Science Center, College of Medicine, Temple, TX, United States of America
    Search for articles by this author
  • Austin Essenburg
    Baylor Scott and White Health, Central Region, Department of Emergency Medicine, Texas A&M Health Science Center, College of Medicine, Temple, TX, United States of America
    Search for articles by this author
Published:October 22, 2018DOI:


      Appendicitis is the most common surgical emergency in children, of which most are located in the retrocecal space or pelvis. Appendicitis occurring in the subhepatic space is uncommon and may present with atypical features such as right upper quadrant pain, leading to delayed diagnosis and complications. We present a rare case of subhepatic appendicitis in an 11-year-old female, who presented with a three-day history of both right upper quadrant (RUQ) and right lower quadrant (RLQ) abdominal pain and serum lipase elevated four times the upper normal limit. The abdominal ultrasound was normal, except for prominent RLQ abdominal lymph nodes. Hours later, a computed tomography scan revealed a non-ruptured subhepatic appendicitis and normal pancreas. Our patient encounter demonstrates the need to be aware of the atypical presentations of pediatric appendicitis in general and subhepatic appendicitis in particular. Moreover, to our knowledge, this is the first reported case of elevated lipase (with a radiographically normal pancreas) in association with subhepatic appendicitis. Providers should be aware elevated serum lipase levels may be due to conditions other than pancreatitis and further evaluation should be considered if the elements of the clinical picture are incongruent.
      To read this article in full you will need to make a payment
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'


      Subscribe to The American Journal of Emergency Medicine
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect


        • Stringer M.D.
        Acute appendicitis.
        J Paediatr Child Health. 2017 Nov; 53: 1071-1076
        • Almaramhy H.H.
        Acute appendicitis in young children less than 5 years: review article.
        Ital J Pediatr. 2017; 43: 15
        • Rangarajan M.
        • Palanivelu C.
        • Senthilkumar R.
        • et al.
        Appendicular abscess masquerading as a liver abscess: value of laparoscopy in diagnosis and management.
        Intern J Surg. 2006; 4: 1-4
        • Nayak S.B.
        • George B.M.
        • Mishra S.
        • et al.
        Sessile ileum, subhepatic cecum, and uncinate appendix that might lead to a diagnostic dilemma.
        Anat Cell Biol. 2013; 46: 296-298
        • King A.
        Subhepatic appendicitis.
        Arch Surg. 1955; 71: 265
        • Lockwood C.B.
        On Abnormalities of the Caecum and Colon with Reference to Development. II. Abnormality of the Colon: A Cause of Unsuccessful Colotomy.
        Date accessed: August 31, 2018
        • Palanivelu C.
        • Rangarajan M.
        Laprascopic appendectomy for appendicitis in uncommon situations: the advantages of a tailored approach.
        Singapore Med J. Aug 2007; 48: 737-740
        • Becker T.
        • Kharbanda A.
        • Bachur R.
        Atypical clinical features of pediatric appendicitis.
        Acad Emerg Med. 2007; 14: 124
        • Samuel M.
        Pediatric appendicitis score.
        J Pediatr Surg. June 2002; 37: 877-881
        • Kharbanda A.B.
        • Vazquez-Benitez G.
        • Ballard D.W.
        • et al.
        Development and validation of a novel Pediatric Appendicitis Risk Calculator (pARC).
        Pediatrics. 2018; 141 ([Epub 2018 Mar 13])
        • Chong H.C.
        • Chai F.Y.
        • Balakrishnan D.
        • et al.
        Malrotated subhepatic caecum with subhepatic appendicitis: diagnosis and management.
        Case Rep Surg. 2016; 2016 ([Epub 2016 Aug 25]): 6067374
        • Ball W.R.
        • Privitera A.
        Subhepatic appendicitis: a diagnostic dilemma.
        BMJ Case Rep. 2013; ([published online 18 April 2013])
        • Le Coz J.
        • Orlandini S.
        • Titomanlio L.
        • et al.
        Point of care ultrasonography in the pediatric emergency department.
        Ital J Pediatr. 2018; 4487
        • Evrimler S.
        • Okumuser I.
        • Unal N.
        Computed tomography (CT) findings of a diagnostic dilemma: atypically located acute appendicitis.
        Pol J Radiol. 2016; 81: 583-588
        • Ong E.M.W.
        • Venkatesh S.K.
        Ascending retrocecal appendicitis presenting with right upper abdominal pain: utility of computed tomography.
        World J Gastroenterol WJG. 2009; 15: 3576-3579
        • Singh S.
        • Jha A.K.
        • Sharma N.
        • et al.
        A case of right upper abdominal pain misdiagnosed on computerized tomography.
        Malays J Med Sci MJMS. 2014; 21: 66-68
        • Galván-Montaño A.
        • Flores-Nava G.
        • Suárez-Roa Mde L.
        • et al.
        Subhepatic appendicitis with subdiaphragmatic abscess in a pediatric patient without intestinal malrotation: case report.
        Cir Cir. 2010 Jan–Feb; 78: 79-81
        • Aneiros Castro B.
        • Cano Novillo I.
        • García Vázquez A.
        • et al.
        Is the laparoscopic approach appropriate for pediatric subhepatic appendicitis?.
        Asian J Endosc Surg. 2018 Feb 19;
        • Hameed A.M.
        • Lam V.W.T.
        • Pleass H.C.
        Significant elevations of serum lipase not caused by pancreatitis: a systematic review.
        HPB Off J Int Hepato Pancreato Biliary Assoc. 2015; 17: 99-112
        • Restrepo R.
        • Hagerott H.E.
        • Kulkarni S.
        • et al.
        Acute pancreatitis in pediatric patients: demographics, etiology, and diagnostic imaging.
        Am J Roentgenol. 2016; 206: 632-644