Background A pyonephrosis caused by an obstructing calculus is typically accompanied by fever, loin pain, and other signs of urinary tract infection. Occasionally, severe thinning of the renal parenchyma in pyonephrosis allows direct forniceal rupture into the retroperitoneum and very rarely into the anterior abdominal wall, misconstruing it as an isolated abdominal wall abscess. Case presentation Diabetes-related 55-year-old diabetic male presented with abscess in his periumbilical region extending into right lumbar region. He did not exhibit any urinary symptoms, and contrast enhanced computed tomography [CECT] abdominal and pelvic examinations revealed right pelvic calculus with pyonephrosis. There is a 7.5 mm defect in the lower pole of the right kidney with 171 cc of collection adjacent to the kidney communicating with 150 cc of superficial abdominal wall collection through a 15 mm defect. Incision and drainage of abdominal and retroperitoneal abscesses were done at first. Right DJ stenting was performed. Right lateral decubitus was placed for dependent drainage. Resolution of residual collections was confirmed by subsequent ultrasonography KUB, and drain was then removed. Right DJ stenting done, and patient was discharged. Two months later, DTPA scan done and revealed GFR of 30 ml/min of right kidney. Patient underwent right percutaneous nephrolithotomy. Conclusion The sudden rupture of pyonephrosis is a rare event. Even rarer is the presentation of pyonephrosis as an abscess on the anterior abdominal wall. The correct diagnosis and search for the source of the abscess must be undertaken before intervention. An aggressive and prompt management is needed to prevent further complications from occurring. This case is being presented to add to the literature with regard to abnormal presentations of ruptured pyonephrosis and its management.

Background: Acute appendicitis is one of the most common surgical emergencies encountered routinely. The classic symptoms occur in just over half of patients with acute appendicitis therefore, an accurate and timely diagnosis of atypical appendicitis remains clinically challenging. Aim: The aim of this study was to determine the incidence of atypical presentations among patients diagnosed with appendicitis, to investigate which atypical features are the strongest positive predictors for appendicitis among patients being evaluated for appendicitis and to determine whether atypical presentation has any role in modifying conventional management strategies. Materials and Methods: Case files of 100 patients admitted and treated in a tertiary referral centre from January 2016 to January 2018 with confirmed diagnosis of appendicitis were retrospectively analysed for the variability in their clinical presentation and the data was correlated with intra-operative findings. The management strategy employed for each patient was studied with emphasis on any modification employed for atypical cases. Summary: 34% of patients in study population had features of atypical appendicitis. The most common agegroup with atypical cases were 11-20 (24%). The most common symptom in atypical cases was pain(100%) followed by nausea/vomiting(41%), fever(35%), urinary symptoms(35%), diarhhoea (12%) and vaginal discharge(6%). The most common sign on abdominal examination in atypical cases was localised tenderness(30%) followed by localised guarding/rigidity(12%), rovsing's sign(6%), psoas sign(6%) and obturator sign(6%). Diagnostic accuracy of ultrasound and CT abdomen in atypical cases was very high being 82% and 100% respectively. Despite the atypical presentations the treatment in majority cases remained operative with laparoscopic appendicetomy (59%) being most common followed by standard appendicectomy(12%), while 29% of patients were treated with conservative management. Conclusion: Knowledge about the variable presentations of atypical uncomplicated appendicitis, a very common condition can aid in timely and confident diagnosis and intra-operative location of appendix can be presumed. However, the management in such cases is not dependent on clinical presentation in uncomplicated cases but depends on patient's comorbidities and surgeon's discretion.

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