RETROPERITONEAL RETROCOLIC APPENDICITIS PRESENTING AS DIFFUSE ABDOMINAL PAIN: A SURGICAL DILEMMA — CASE REPORT AND REVIEW OF THE LITERATURE

Abstract

Background: Acute appendicitis is among the most common surgical emergencies. However, when the appendix assumes a retroperitoneal or retrocolic location, typical clinical presentations and signs may be absent or misleading, complicating timely diagnosis and management.

Case Presentation: A 48-year-old postmenopausal woman presented with three days of diffuse, insidious abdominal pain—worsened over the last eight hours—accompanied by two non-bilious, non-bloody episodes of vomiting. Vital signs were notable for tachycardia (108 bpm) and low-grade fever (99.1 °F). Examination revealed a soft abdomen with diffuse tenderness and guarding and sluggish bowel sounds. Per rectal examination was normal. CT imaging suggested appendicitis in a post-ileal position. Intraoperatively, a retroperitoneal, retrocolic inflamed appendix was identified and removed via a retroperitoneal approach.

Discussion: This case highlights the diagnostic and surgical challenges posed by atypical appendiceal anatomy. Literature reveals similar rare presentations including retroperitoneal abscesses, perforations into the retroperitoneum causing thigh or psoas involvement, and misdiagnoses as neoplastic processes involving adjacent structures—such as the ureter—emphasizing the need for high clinical suspicion and flexible operative planning.

Conclusion: Atypical presentations of appendicitis should prompt consideration of anomalous anatomical locations and complications. Advanced imaging and operative preparedness are critical to avoid delayed diagnosis and prevent complications.