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Periappendicitis presenting as left renal colic
PERIAPPENDICITIS LEFT RENAL ALLAN JEFFREY
L. HAYNES,
PRESENTING
AS
COLIC M.D.
R. WOODSIDE,
M.D.
From the Division of Urology, University of New Mexico School of Medicine, Albuquerque, New Mexico
ABSTRACT - Periappendicitis, a variant of appendicitis, is histologically diagnosed in only about 5 per cent of appendices removed for presumptive acute appendicitis. We herein describe a boy with periappendicitis whose clinical presentation was that of left renal colic and partial left midureteral obstruction. Appendicitis not infrequently simulates right ureteral colic. However, to our knowledge appendiceal injlammation never has been reported to simulate left ureteral colic. Also. complications of appendicitis are known to cause right ureteral obstruction (rarely bilateral) but have not been reported to cause solitary left ureteral obstruction. We found no previously reported case of solitary left ureter-al obstruction from appendiceal infEammation or of periappendicitis causing a serious urologic complication. ________~------~
Symptoms of genitourinary disease frequently simulate those of gastrointestinal disorders, particularly in children. Less commonly, various intra-abdominal diseases mimic genitourinary disorders. The many possible intra-abdominal positions of the appendix account for the wide variety of clinical symptoms and complications which may be produced by appendicitis. While the urologic manifestations of appendicitis are usually minor, severe complications can result if abscess formation occurs. Periappendicitis, an inflammation of the serosa of the appendix with minimal involvement of the mucosa and muscular&, is an unusual variant of appendicitis. We describe a patient with abdominal pain, hematuria, and left ureteral obstruction as a result of periappendicitis. In an extensive literature review, we found no similar case reported previously. Case Report A fourteen-year-old Navajo tially in another hospital hematuria, severe left lower and a temperature of 101.8” week history of intermittent,
UROLOGY
/
DECEMBER1980
boy was seen iniwith gross total abdominal colic, F. He had a sixmild left lower ab-
/ VOLUMEXVI,
NUMBER6
dominal colic with no other urologic or gastrointestinal symptoms. He had no history of urolithiasis. Urinalysis revealed pyuria and microscopic hematuria. The white blood cell count was 18,900 with a left shift. He was treated with ampicillin for presumed cystitis, however the pretreatment urine culture was later reported as sterile. When an intravenous pyelogram demonstrated a partial left midureteral obstruction with mild hydroureteronephrosis, he was referred to our institution. On admission he was afebrile and pain-free, and the white blood cell count was 10,800 with a normal differential. Urinalysis showed microhematuria. Serum calcium, phosphorus, uric and creatinine were normal. The acid, creatinine clearance was 92 ml./min. Evaluation for tuberculosis was negative. An intravenous pyelogram confirmed partial left midureteral obstruction (Fig. IA). Results of cystoscopic examination were normal. A left retrograde pyelogram showed partial obstruction of the midureter compatible with extrinsic compression, but also suggested a faintly radiopaque ureteral calculus (Fig. 1B). At surgical exploration the left ureter, iliac artery, and iliac vein were found encased in a dense,
611
FIGURE 1. (-4) lntravenom pyelogrclru .shvwing partial lc.ft midurcteral obstruction with mild hydrtmreteronephrosis. [B) Left retrograde p yelogram showing purtid miclureteral obstruction from extrinsit compression und suggesting faintly ratliopuc~w ureteral culculits. (C 1 Postoperatioe intrat-enoru pyelogram shozcing resolution of ureteral obstruction.
fibrotic, nonfluctuant retroperitoneal mass which also involved the mesentery of the sigmoid colon. Intraperitoneal exploration revealed a normal cecum and a very long and grossly normalappearing appendix which traversed to the left side of the peritoneal cavity. Its tip was densely adherent to the fibrotic inflamtnatory-appearing mass in the sigmoid mesocolon. No pus could be aspirated from the mass. Biopsy of the mass, appendectomy, and ureterolysis were performed. Cultures for aerobic and anaerobic organisms were sterile. Postoperatively, he received penicillin and tetracycline intravenously and had an uneventful recovery. Eight weeks lapyelogram showed resoluter, an intravenous tion of the ureteral obstruction (Fig. 1CJ. Microscopic examination of the apl>endix demonstrated a markedly thickened and fibrotic wall with a moderate diffuse and chronic inflammatory cell infiltrate. The lamina propria had only mild chronic inflammation. Of particular interest was marked serosal inflammation
612
with abundant organizing fibrinoid material (Fig. 2). The biopsy of the wall of the mass showed fibrosis, granulation tissue, and chronic inflammation. Comment Urologic complications of appendicitis are infrequent and usually not serious, but occasionally may be life-threatening. The most common Inanifestations are pyuria and hematuria caused by retrocecal appendicitis producing right periureteritis. ’ Urinary frequency, dysuria, ant 1 urinary retention are seen occasionally.2 Appendiceal rupture with sllbsequent abscess forlnation has reslllted in appendicovesical fist&, perinephric abscess, symptoms of bladder outlet obstruction , and right ureteral obstruction. I-6 Although rare. even bilateral ureteral obstruction has been reported. 7 Pcriappendicitis receives scant attention in standard textbooks, and, indeed, its existence as a disease entity has been questioned.
~JROLOCY
i
DE(:EMBER
1980
/
VOLUME
XVI,
NUMBER
6
FIGURE 2. Photomicrograph of appendix demonstrating thickened and jibrotic wall with minimal inflammation and marked serosal inflammation with abundant organizing jibrinoid material jhematorylin and eosin stain, original magn$cation x 39).
pendicitis or a neglected appendicitis in which the mucosal inflammation had largely subsided. O’Neil and Moore” found a similar incidence (5.4 per cent) of periappendicitis in 224 appendices removed for the preoperative diagnosis of appendicitis. Seven of their 12 cases were associated with salpingitis. They speculated that periappendicitis not associated with salpingitis represented a healing stage of appendicitis. We found no report of urologic complications of periappendicitis. Both the clinical presentation and the etiology of the ureteral obstruction in our patient were unusual. Gross hematuria, left lower abdominal colic, and partial left midureteral obstruction demonstrated on both intravenous and retrograde pyelograms were highly suggestive of a ureteral stone. We thought extrinsic compression from retroperitoneal fibrosis or tumor was less likely. Although others have described appendicitis presenting as right ureteral colic,” it was not even in our differential diagnosis of left ureteral colic. The pathologic examination of our patient’s appendix was compatible with periappendicitis of the juvenile type rather than typiTo our knowledge, this cal acute appendicitis. represents the first reported case of solitary left ureteral obstruction from appendiceal inflammation and the first serious urologic complication of periappendicitis. 2211 Lomas Boulevard NE Albuquerque, New Mexico 87131 (DR. WOODSIDE) Heferences
In an extensive review, Gordon8 histologically examined 26,051 appendices and found a 5.69 per cent incidence of periappendicitis. The occurrence was highest in males below the age of twelve and in females between the ages of seventeen and twenty-one. He classified periappendicitis into secondary and juvenile types. The secondary type was usually the result of concomitant salpingitis, which correlated with its high incidence in females during their sexually active years. Histologically, this type had serosal inflammation with no noteworthy changes in the remaining coats of the wall. In contrast, the juvenile type showed slight submucosal inflammation, more obvious muscularis inflammation, and a marked serosal inflammatory reaction. He thought that the juvenile type represented either a fulminating ap-
UROLOGY
DECEMBER
1980
/
VOLUME
XVI,
NUMBER
1. Lazarus J.4, and Marks MS: Urological manifestations associated with chronic appendiceal abscess, Am. J, Surg. 68: 38 (1945). 2. Cook GT: Appendiceal abscess causing urinary obstruction, J. Urol. 101: 212 (1969). 3. Richie JP, Sacks SA, Rhodes D, and Skinner DG: Urologic complications of appendicitis, Urology 6: 689 (1975). 4. Hyman S, and Capos NS: Appendiceal-vesical fistula; mcommon complication of acute perforative appendicitis with report of three cases, JAbfA 170: 2177 (1959). 5. Ha&n HC, and Hamm FC: Urologic disease resulting from nonspecific inflammatory conditions of the bowel, J. Errol. 68: 383 (1952). 6. Carroll R, and Lau&ton JM: Obstructive uropathy due to unusual pelvic swellings, Proc. R. Sot. Med. 66: lM7 (1973). 7. Kaplan GW, and Keiller DL: Ureteral obstruction after appendectomy, J. Pediatr. Surg. 9: 559 (1971). 8. Gordon H: Periappendicitis without appendicitis, a stud! based on 26,051 appendices, Arch. Pathol. 19: 185 (1935). 9. O’Neil MB, and ,Moore DB: Periappendicitis: clinical reality or pathologic curiosity, Am. J. Surg. 134: 356 (1977). 10. Hardie GH, and Berry REL: Acute appendicitis simulating right ureterolithiasis: a case report, Univ. Mich BIIII. 22: 306 (1956).
6
613
L. HAYNES,
PRESENTING
AS
COLIC M.D.
R. WOODSIDE,
M.D.
From the Division of Urology, University of New Mexico School of Medicine, Albuquerque, New Mexico
ABSTRACT - Periappendicitis, a variant of appendicitis, is histologically diagnosed in only about 5 per cent of appendices removed for presumptive acute appendicitis. We herein describe a boy with periappendicitis whose clinical presentation was that of left renal colic and partial left midureteral obstruction. Appendicitis not infrequently simulates right ureteral colic. However, to our knowledge appendiceal injlammation never has been reported to simulate left ureteral colic. Also. complications of appendicitis are known to cause right ureteral obstruction (rarely bilateral) but have not been reported to cause solitary left ureteral obstruction. We found no previously reported case of solitary left ureter-al obstruction from appendiceal infEammation or of periappendicitis causing a serious urologic complication. ________~------~
Symptoms of genitourinary disease frequently simulate those of gastrointestinal disorders, particularly in children. Less commonly, various intra-abdominal diseases mimic genitourinary disorders. The many possible intra-abdominal positions of the appendix account for the wide variety of clinical symptoms and complications which may be produced by appendicitis. While the urologic manifestations of appendicitis are usually minor, severe complications can result if abscess formation occurs. Periappendicitis, an inflammation of the serosa of the appendix with minimal involvement of the mucosa and muscular&, is an unusual variant of appendicitis. We describe a patient with abdominal pain, hematuria, and left ureteral obstruction as a result of periappendicitis. In an extensive literature review, we found no similar case reported previously. Case Report A fourteen-year-old Navajo tially in another hospital hematuria, severe left lower and a temperature of 101.8” week history of intermittent,
UROLOGY
/
DECEMBER1980
boy was seen iniwith gross total abdominal colic, F. He had a sixmild left lower ab-
/ VOLUMEXVI,
NUMBER6
dominal colic with no other urologic or gastrointestinal symptoms. He had no history of urolithiasis. Urinalysis revealed pyuria and microscopic hematuria. The white blood cell count was 18,900 with a left shift. He was treated with ampicillin for presumed cystitis, however the pretreatment urine culture was later reported as sterile. When an intravenous pyelogram demonstrated a partial left midureteral obstruction with mild hydroureteronephrosis, he was referred to our institution. On admission he was afebrile and pain-free, and the white blood cell count was 10,800 with a normal differential. Urinalysis showed microhematuria. Serum calcium, phosphorus, uric and creatinine were normal. The acid, creatinine clearance was 92 ml./min. Evaluation for tuberculosis was negative. An intravenous pyelogram confirmed partial left midureteral obstruction (Fig. IA). Results of cystoscopic examination were normal. A left retrograde pyelogram showed partial obstruction of the midureter compatible with extrinsic compression, but also suggested a faintly radiopaque ureteral calculus (Fig. 1B). At surgical exploration the left ureter, iliac artery, and iliac vein were found encased in a dense,
611
FIGURE 1. (-4) lntravenom pyelogrclru .shvwing partial lc.ft midurcteral obstruction with mild hydrtmreteronephrosis. [B) Left retrograde p yelogram showing purtid miclureteral obstruction from extrinsit compression und suggesting faintly ratliopuc~w ureteral culculits. (C 1 Postoperatioe intrat-enoru pyelogram shozcing resolution of ureteral obstruction.
fibrotic, nonfluctuant retroperitoneal mass which also involved the mesentery of the sigmoid colon. Intraperitoneal exploration revealed a normal cecum and a very long and grossly normalappearing appendix which traversed to the left side of the peritoneal cavity. Its tip was densely adherent to the fibrotic inflamtnatory-appearing mass in the sigmoid mesocolon. No pus could be aspirated from the mass. Biopsy of the mass, appendectomy, and ureterolysis were performed. Cultures for aerobic and anaerobic organisms were sterile. Postoperatively, he received penicillin and tetracycline intravenously and had an uneventful recovery. Eight weeks lapyelogram showed resoluter, an intravenous tion of the ureteral obstruction (Fig. 1CJ. Microscopic examination of the apl>endix demonstrated a markedly thickened and fibrotic wall with a moderate diffuse and chronic inflammatory cell infiltrate. The lamina propria had only mild chronic inflammation. Of particular interest was marked serosal inflammation
612
with abundant organizing fibrinoid material (Fig. 2). The biopsy of the wall of the mass showed fibrosis, granulation tissue, and chronic inflammation. Comment Urologic complications of appendicitis are infrequent and usually not serious, but occasionally may be life-threatening. The most common Inanifestations are pyuria and hematuria caused by retrocecal appendicitis producing right periureteritis. ’ Urinary frequency, dysuria, ant 1 urinary retention are seen occasionally.2 Appendiceal rupture with sllbsequent abscess forlnation has reslllted in appendicovesical fist&, perinephric abscess, symptoms of bladder outlet obstruction , and right ureteral obstruction. I-6 Although rare. even bilateral ureteral obstruction has been reported. 7 Pcriappendicitis receives scant attention in standard textbooks, and, indeed, its existence as a disease entity has been questioned.
~JROLOCY
i
DE(:EMBER
1980
/
VOLUME
XVI,
NUMBER
6
FIGURE 2. Photomicrograph of appendix demonstrating thickened and jibrotic wall with minimal inflammation and marked serosal inflammation with abundant organizing jibrinoid material jhematorylin and eosin stain, original magn$cation x 39).
pendicitis or a neglected appendicitis in which the mucosal inflammation had largely subsided. O’Neil and Moore” found a similar incidence (5.4 per cent) of periappendicitis in 224 appendices removed for the preoperative diagnosis of appendicitis. Seven of their 12 cases were associated with salpingitis. They speculated that periappendicitis not associated with salpingitis represented a healing stage of appendicitis. We found no report of urologic complications of periappendicitis. Both the clinical presentation and the etiology of the ureteral obstruction in our patient were unusual. Gross hematuria, left lower abdominal colic, and partial left midureteral obstruction demonstrated on both intravenous and retrograde pyelograms were highly suggestive of a ureteral stone. We thought extrinsic compression from retroperitoneal fibrosis or tumor was less likely. Although others have described appendicitis presenting as right ureteral colic,” it was not even in our differential diagnosis of left ureteral colic. The pathologic examination of our patient’s appendix was compatible with periappendicitis of the juvenile type rather than typiTo our knowledge, this cal acute appendicitis. represents the first reported case of solitary left ureteral obstruction from appendiceal inflammation and the first serious urologic complication of periappendicitis. 2211 Lomas Boulevard NE Albuquerque, New Mexico 87131 (DR. WOODSIDE) Heferences
In an extensive review, Gordon8 histologically examined 26,051 appendices and found a 5.69 per cent incidence of periappendicitis. The occurrence was highest in males below the age of twelve and in females between the ages of seventeen and twenty-one. He classified periappendicitis into secondary and juvenile types. The secondary type was usually the result of concomitant salpingitis, which correlated with its high incidence in females during their sexually active years. Histologically, this type had serosal inflammation with no noteworthy changes in the remaining coats of the wall. In contrast, the juvenile type showed slight submucosal inflammation, more obvious muscularis inflammation, and a marked serosal inflammatory reaction. He thought that the juvenile type represented either a fulminating ap-
UROLOGY
DECEMBER
1980
/
VOLUME
XVI,
NUMBER
1. Lazarus J.4, and Marks MS: Urological manifestations associated with chronic appendiceal abscess, Am. J, Surg. 68: 38 (1945). 2. Cook GT: Appendiceal abscess causing urinary obstruction, J. Urol. 101: 212 (1969). 3. Richie JP, Sacks SA, Rhodes D, and Skinner DG: Urologic complications of appendicitis, Urology 6: 689 (1975). 4. Hyman S, and Capos NS: Appendiceal-vesical fistula; mcommon complication of acute perforative appendicitis with report of three cases, JAbfA 170: 2177 (1959). 5. Ha&n HC, and Hamm FC: Urologic disease resulting from nonspecific inflammatory conditions of the bowel, J. Errol. 68: 383 (1952). 6. Carroll R, and Lau&ton JM: Obstructive uropathy due to unusual pelvic swellings, Proc. R. Sot. Med. 66: lM7 (1973). 7. Kaplan GW, and Keiller DL: Ureteral obstruction after appendectomy, J. Pediatr. Surg. 9: 559 (1971). 8. Gordon H: Periappendicitis without appendicitis, a stud! based on 26,051 appendices, Arch. Pathol. 19: 185 (1935). 9. O’Neil MB, and ,Moore DB: Periappendicitis: clinical reality or pathologic curiosity, Am. J. Surg. 134: 356 (1977). 10. Hardie GH, and Berry REL: Acute appendicitis simulating right ureterolithiasis: a case report, Univ. Mich BIIII. 22: 306 (1956).
6
613