Perforated sub-hepatic appendix; rare presentation of a common disease

An elderly gentleman presented to our emergency with a 10-day history of right upper quadrant pain and nausea with associated tenderness on examination. his white cell counts were raised with predominant neutrophils with ultrasound evidence of a heterogeneous sub-hepatic collection,not associated with fever,diarrhoea or vomiting. he had a similar episode 3 weeks ago,which resolved with antibiotics. initially thought to be a perforated acute appendicitis or a liver abscess a ct scan was done to further substantiate our finding. this to the contrary revealed a perforated sub hepatic appendix. patient was treated conservatively with iv fluids and antibiotics and the sub hepatic collection was aspirated under ultrasound guidance. he responded well to treatment and made an uneventful recovery. © 2016,pakistan medical association. all rights reserved.