Inflammatory stricture of the right ureter following perforated appendicitis: The first Indian report.

Perforated appendicitis leading to inflammatory stricture of the right ureter is a rarity. We present this fairly uncommon case of a patient who developed a stricture of the right ureter secondary to an ongoing inflammatory process in the peritoneum and retroperitoneum. A perforated appendicitis was operated upon, and on follow-up the mild hydronephrosis had worsened. Stenting of the right ureter completely solved the problem.

INTRODUCTION

Inflammatory stricture of the ureter can follow percutaneous nephrolithotomy (PCNL), ureteric stenting or instrumentation and retained or impacted stones in the ureter, as part of methysergide-related retroperitoneal fibrosis or very rarely secondary to inflammatory diseases[1] or adhesions[2] of the peritoneal cavity spreading its confines into the retroperitoneum.

CASE REPORT

A 58-year-old woman presented with acute inflammatory features in the right iliac fossa. An ultrasound showed a small collection of fluid and debris in the free peritoneal cavity in the right iliac fossa with a thickened tubular structure, probably the perforated appendix. There was also a note in the ultrasound scan about mild pelvicalyceal dilatation of the right kidney. After discussing with the urologist, we proceeded with an emergency diagnostic laparoscopy and found a perforated appendix with abscess, inflammatory exudate and adhesions in the right iliac fossa [Figure 1]. By suction dissection, the appendix was freed from the surrounding structures and an appendectomy was performed. The peritoneal cavity was thoroughly washed out with normal saline and a drain was kept through the suprapubic port. The immediate postoperative period was uneventful. At follow-up after 2 weeks, she had right loin pain; a repeat ultrasound was taken, as advised earlier by the urologist, which showed more significantly dilated ureter accompanying the hydronephrosis. This dilated ureter was traceable up to the terminal portion about 2.5-3 cm proximal to the ureterovesical junction. There was no free fluid in the peritoneal cavity. We sent the patient for contrast-enhanced computed tomography (CT) scan, which showed diffuse inflammatory changes of the retroperitoneum on the right side. The dilatation of the ureter was confirmed up to its terminal portion, and there was no stone or intraluminal pathology obviously seen on the CT [Figure 2]. A thickening of the ureter was also noticed in relation to the terminal ileum and the appendicular area, and it was suggested that it was likely to be an inflammatory stricture of the right ureter [Figure 3].

Figure 1

Perforated appendix with abscess, inflammatory exudate and adhesions in the right iliac fossa

Figure 2

(a) Coronal section 2 (b) Axial section: The dilatation of the ureter was confirmed up to its terminal portion in computed tomography

Figure 3

Inflammatory stricture of the right ureter

As the dilatation of the ureter had increased compared to the time of surgery and as the patient was quite symptomatic with right loin pain, we proceeded to decompress the dilated collecting system with an immediate ureterorenoscopy (URS), which showed narrowing of the distal ureter due to extrinsic pathology; hence, stenting of the right ureter was performed. This was duly performed within 24 h of the contrast-enhanced computed tomography (CECT) and the patient was discharged on the following day. At the follow-up 4 weeks after the stenting, she was found to have no symptom of right iliac fossa or loin pain. A follow-up ultrasound showed no dilatation of the ureter or the collecting system. The stent was removed after 6 weeks following which the patient has remained asymptomatic at 30 days follow-up.

DISCUSSION

Although medical literature has well-documented ureteric obstruction secondary to appendicular inflammation, the case reports of this entity are few and far-spaced. We could find no report of this problem from the Indian subcontinent. A partial unilateral or bilateral[34] hydronephrosis or pelvicalyceal dilatation seen at the time of acute appendicitis is not quite uncommon but this usually resolves spontaneously after appendectomy is performed[5] and the inflammatory oedema settles down. Many causes have been putatively described for hydronephrosis of acute appendicitis, starting from inflammatory compression, adhesions[2] to a uretero-appendiceal fistula, especially in the rare appendicular actinomycosis where the spreading fungal infection causes an intense inflammatory reaction and progressive fibrosis.[6] One must also bear in mind, especially for older patients, that malignancy of the colon or the adnexae could also incidentally cause appendicitis and hydronephrosis. The CT is an invaluable modality of investigation as it gives a clear diagnosis and rules out coincidental pathology. The ultrasound is a good follow-up tool and we were able to follow up the progressive resolution to normal of the dilated pelvicalyceal system.

In our case there was no evidence of malignancy of the colon or adnexae, the appendix histopathology shows a perforated appendicitis but no actinomycosis.

In some of the reported patients the inflammatory ureteric stricture and hydronephrosis were so severe that a Boari flap[7] had to be performed and a partial resection of the stenotic segment of the ureter had to be performed. So our timely intervention with URS and stenting solved the problem completely. Incidentally the available case reports indicate that the appendicitis related to ureteric stricture is usually a complicated type of appendicitis, and our case was also a perforated appendix with a stercolith.

Finally a recent meta-analysis[8] showed that in young male patients, the ultrasound had a significant advantage in the diagnosis of appendicitis. However, we recommend a CECT in complicated appendicitis; a CT scan if available is able to shed much more light on the diagnosis and helps to plan the most appropriate treatment in the available scenario.

A well-known but a little discussed entity is ureteric obstruction secondary to complicated appendicitis. A survey of the available literature afforded us a couple of valuable nuggets, which we would like to share as our carry-home messages:

A CECT scan for a complicated appendicitis patient will often help differentiate other pathologies in the adnexae, the colon, or hydronephrosis.

In the follow-up of patients with severe appendicitis and hydronephrosis seen on ultrasound, it is worthwhile to repeat the ultrasound to ensure that the hydronephrosis has settled and if there is worsening of the pelvicalyceal dilatation, proceeding with the CECT scan is strongly recommended.

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Conflicts of Interest

There are no conflicts of interest.