• Alfonso Galván-Montaño, Gerardo Flores-Nava, María de Lourdes Suárez-Roa, María Cristina Salazar-Herrera, and Antonio Lavalle-Villalobos.
• Subdirección de Pediatría, División Pediatría Médica, Hospital General "Dr. Manuel Gea González," México, D.F., Mexico. gamagq3@hotmail.com
• Cir Cir. 2010 Jan 1;78(1):79-81.

BackgroundAcute subhepatic appendicitis in children is an uncommon presentation. It is usually associated with intestinal malrotation. When these conditions are met, accurate diagnosis and early management decisions are delayed.Clinical CaseWe present the case of a 10-year-old male who had diarrhea without mucus or blood for 5 days. He was treated with antibiotics. Afterwards, he presented with vomiting, abdominal pain, and fever. Physical examination of the abdomen demonstrated a soft and depressible mass and pain in the lower right abdomen. Abdominal ultrasound and tomography reported image of subdiaphragmatic abscess. Percutaneous puncture and drainage were performed without results. Exploratory laparotomy was then performed, revealing a subhepatic perforation of the appendix. The patient evolved with abdominal sepsis and septic shock, resulting in a new surgical intervention for drainage of serohematic fluid. The patient improved and was discharged on day 40.DiscussionIt is very important to consider the position of the anatomic appendix during appendicitis because it contributes to the various clinical symptoms, of which 30% are atypical. Diagnosis is masked, leading to complications such as perforations and/or abscesses that extend the hospital stay.ConclusionsAcute subhepatic appendicitis in children is an uncommon presentation. It is usually associated with intestinal malrotation. Delay in treatment due to atypical symptoms caused by the abnormal position of the appendix conditioned complications that implied a prolonged hospital stay, with the risk of increasing morbidity and mortality of the patient.

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