Acute synchronous appendicitis and obstructing ureterolithiasis.

This is an unusual case of a patient presenting to the Emergency Room with right-sided abdominal pain and subsequently 2 acute diagnoses were made. The patient had both acute appendicitis and acute ureterolithiasis.

Introduction

The teaching point of this case applies to all practitioners, especially those in the emergency medicine setting. More than 1 of the considered differential diagnoses may apply to a single patient. The physician, particularly the Emergency radiologist, should not be restricted by “satisfaction of search.”

Case report

A 34-year-old male with no significant past medical history presented to our Emergency Room with a 1-day history of right flank pain as well as right lower quadrant pain. The patient reported subjective fevers and chills as well as nausea but no emesis and normal bowel function. No dysuria or hematuria was reported.

In the Emergency Room, the patient was afebrile. The patient was tolerating food and drink. On physical examination, the patient's abdomen was soft and nontender with right lower quadrant abdominal tenderness to palpation, but without rebound or guarding.

Laboratory data was asignificant for mild leukocytosis with a WBC of 12.3 with 76% neutrophils. Urinalysis was only significant for trace leukocyte esterase.

The differential diagnosis included renal stone and appendicitis.

A CT with intravenous and oral contrast was obtained and was remarkable for a 6.5 × 3.5 mm proximal right ureteral calculus (Fig. 1) with moderate proximal hydroureter and mild hydronephrosis (Fig. 2). There was delayed excretion of contrast from the right kidney. In addition, inflammatory changes were noted within the right lower quadrant as well as an unopacified and mildly prominent appendix (Fig. 3).

Fig. 1

Obstructing right ureteral calculus (arrow).

Fig. 2

Right hydronephrosis (arrow).

Fig. 3

Abnormal appendix with peripheral stranding (arrow).

Urology was consulted who recommended pain control, Flomax and out-patient follow-up. General surgery was consulted who recommended admission with planned operative management for acute appendicitis.

The patient received antibiotics and pain control and was admitted to the general surgery service and underwent successful laparoscopic appendectomy. Intraoperative findings were significant for an inflamed appendix and murky periappendiceal fluid. The patient's recovery was uneventful. The patient was discharged home tolerating a regular diet on post-operative day 1.

The pathology report obtained after patient discharge showed acute appendicitis and acute peri-appendicitis.

Discussion

Our patient presented as many do with focal abdominal pain and was worked up in standard fashion, which coincidentally revealed 2 separate acute pathologic processes – acute appendicitis and obstructive ureteronephropathy. The patient was treated appropriately and had fully recovered.

A simultaneous diagnosis of acute appendicitis with obstructive ureteronephropathy is exceedingly rare [1], [2]. To our knowledge, this is the first case reported in radiology literature. We felt this case warranted additional and specific radiology exposure to serve as yet another reminder to the radiologist, especially the emergency radiologist, to always be vigilant in his or her evaluation of each and every study and not to succumb to “satisfaction of search.”