Right Ureteric Colic Misdiagnosed as Acute Appendicitis: a Case Report

Abstract

For the patients who present with the acute right lower quadrant (RLQ) pain, the common causes are the acute appendicitis, right ureteric colic and gynecological conditions. They need to be definitely distinguished for the rapid and proper management otherwise it may lead to the unexpected outcome as our case. She was a 55-year-old Thai patient who presented with acute right lower quadrant pain and nausea, vomiting without fever for one day. The physical examination revealed generalized guarding, marked tenderness at McBurney's point with rebound tenderness, and positive Rovsing's sign. The blood tests showed: Hct 33.7%, WBC 17,700/mm³, platelet 480,000/mm³, N 91%, L 8%, serum creatinine 2.1 mg% whereas the urinalysis revealed WBC 50-100/HPF, RBC 3-5/HPF. She was diagnosed as acute appendicitis and immediately treated with appendectomy under the general anesthesia and intravenous cefoxitin and metronidazole. The microscopic pathology of the resected appendix was mild inflammation. She seemed responsive well but two weeks later, she was emergently admitted again because of the sudden onset of fever and septicemia. The blood test showed WBC 12,800/mm³, N 76%, L 13% whereas the urine had WBC 10-20/HPF, and RBC 1-2/HPF. The computerized tomography of the whole abdomen showed the right hydroureter and right hydronephrosis. The upper urinary tract infection with septicemia was diagnosed and parenteral imipenem and metronidazole were administered. The bacterial cultures from the blood and urine yielded nothing. She did not respond to therapy and passed away in 3 days of admission while the right ureteric obstruction was waiting for the surgical correction. If our case had been examined with the computerized tomography of the whole abdomen in the first admission, she would have received the more appropriate management.