Abstract
A
We present a rare case of ruptured retrocecal appendicitis in the third trimester of pregnancy with atypical presentation. A 25-year-old female at the thirty-third week of pregnancy presented with pain in the right lumbar region, leukocytosis, and right renal pelvis dilatation on ultrasound (US), but no fever. Initial diagnosis was that of right renal colic and she was treated as such. Following clinical deterioration, and a substantial decrease in hematocrit, she underwent abdominal US and magnetic resonance imaging (MRI). A large sub-diaphragmatic collection was found, which at first was believed to be a sub-capsular liver hematoma (Fig. 1). It was managed initially non-operatively. Delivery was performed successfully through caesarean section after preparation with corticosteroids. Two days after delivery, the patient developed symptoms and signs of septic shock. Broad-spectrum antibiotics were administered and the sub-diaphragmatic collection was drained percutaneously under computed tomography (CT) guidance. The collection was a large subphrenic abscess. Six months later the patient underwent exploratory laparotomy, in which remnants of a ruptured appendix were discovered in the right sub-hepatic space and removed (Fig. 2).
Abdominal computed tomography (CT) imaging with IV contrast, showing the large abscess in the right liver lobe (asterisk), containing an air bubble (black arrow).
A small fluid collection between the liver and the right kidney, containing an elongated calcified mass, which initially was believed to be a foreign body (black arrow). It was removed six months after the drainage of the abscess, through a laparotomy. Histologic examination showed that it was remnants of a ruptured appendix with focal deposits of hemosiderin.
Abdominal pain during pregnancy calls for sound judgment and careful evaluation, in order to avoid unnecessary and potentially life-threatening complications for both the mother and the fetus. Apart from the atypical location of the appendix inside the abdomen, the female urinary system also undergoes certain alterations as a response to hormonal changes and the ongoing enlargement of the uterus. Both kidneys increase about 1–1.5 cm in diameter and the ureters (as well as the renal pelvis and calyces) may appear with a certain degree of dilation [4]. A thorough research in the literature revealed only one case of subphrenic abscess, in a pregnant woman following chorioamnionitis after caesarean section [5].