Pyometra Presenting as a Right-Lower-Quadrant Abdominal Mass With Right-Sided Bowel Dilatation on Abdominal...

Pyometra is an uncommon uterine infection that predominantly affects postmenopausal females. It can present with non-specific features and may at times mimic gastrointestinal pathology, delaying diagnosis. An 81-year-old female with multiple comorbidities and frailty presented to the emergency department with two weeks of poor oral intake and reduced mobility. She was treated as having sepsis of unclear source with suspected respiratory infection. Despite broad-spectrum intravenous antibiotics, she deteriorated clinically with persistently raised inflammatory markers. She developed abdominal discomfort, constipation, and then abdominal distension and right-sided abdominal tenderness. An abdominal X-ray showed dilated bowel loops on the right. Pelvic magnetic resonance imaging (MRI) demonstrated a markedly distended uterine cavity containing a large fluid collection with an air-fluid level and restricted diffusion, consistent with pyometra. Malignancy could not be excluded on imaging. The case was discussed with gynaecology and microbiology, and antibiotics were escalated. A best interests meeting concluded that definitive management with uterine drainage was too invasive given her frailty and unlikely tolerance. She was managed conservatively with intravenous antibiotics, with transient improvement in delirium and inflammatory markers. This case highlights pyometra as an important differential diagnosis in elderly women presenting with abdominal symptoms and bowel dilatation on imaging. Early pelvic imaging should be considered when sepsis persists without a clear source.