Case of appendicitis-like hyperemesis gravidarum in 33-year-old patient at 14-weeks gestations with history of severe, constant and sharp pain.
A 33-year-old gravida 4 para 3 with hyperemesis gravidarum presented to the emergency at 14-weeks gestation with several days history of constant, sharp, 10/10 right back pain. With the pain radiating to her right flank with nausea and vomiting. However, there was no sign of fever, dysuria, abdominal pain or spinal tenderness on palpation.
The patient had a history of substance abuse, generalised anxiety disorder, bipolar I disorder, preeclampsia, abdominal vein thrombosis and nephrolithiasis. Findings on a previous computed tomography (CT) scan were remarkable of a 1mm right kidney stone. However, the scan did not visualise the appendix. The patient reported similar symptoms with prior episodes of nephrolithiasis. The initial ultrasound did not show hydronephrosis.
She was admitted with complaints of intracable pain and nausea. Infectious work-up, blood culture and urine was negative. The severity of the pain was not attributing to a kidney stone of that size.
Examination and treatment
The labs on admission showed a normal white blood cell count. Although, on the 2nd day of admission, the labs showed leukocytosis and mild hyponatremia. However, the leukocytosis decreased without any intervention on the fourth day,
The patient’s pain did not improve despite frequent doses of parenteral morphine and adjunctive pain therapy. Her pain worsened with vomiting. After this episode doctors were suspecting that the pain is secondary to muscle spasm from frequent emesis. Considering that her pain did not change with movement, positioning and palpation. Further tests rules out other causes. In addition, obstetrics optimised her antiemetic regimen, whereas psychiatry managed her bipolar medication. Magnetic resonance imaging (MRI) and venography (MRV) of the abdomen and pelvis without contrast were remarkable of 12 mm uncomplicated appendicitis without any surrounding inflammatory changes and no signs of perforation.
The findings were consistent with the diagnosis of appendicitis-like hyperemesis gravidarum. Doctors were avoiding surgery because of her pregnancy being borderline second trimester and given her uncomplicated nature of appendicitis. And resorted to administering IV piperacillin-tazobactam for treatment. The patient started showing significant improvement over the following days. She was discharged after completing six days of IV antibiotics.
An Atypical Case of a Common Pregnancy Issue: Appendicitis-Like Hyperemesis Gravidarum https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7387984/