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Emphysematous pyelonephritis in type II diabetes: A case report of an undiagnosed ureteric colic.

Vollans SR, Sehjal R, Forster JA, Rogawski KM - Cases J (2008)

Bottom Line: After four days, a CT was organised as she was not settling.Diabetic patients who are known to have renal or ureteric calculi, whether symptomatic or not, should be considered for percutanous or ureteroscopic treatment.In the acute abdomen, the plain abdominal radiograph should always be viewed with respect to general surgical, vascular and urological differential diagnoses.

View Article: PubMed Central - HTML - PubMed

Affiliation: Department of Urology, Huddersfield Royal Infirmary, Acre Street, Lindley, Huddersfield, HD3 3EA, UK. krogawski@doctors.org.uk.

ABSTRACT

Introduction: Emphysematous pyelonephritis (EPN) is a severe acute necrotising infection of the renal parenchyma and perirenal tissue, characterised by gas formation. 90% of cases are seen in association with diabetes mellitus. We report a case of undiagnosed ureteric obstruction in a type II diabetic, leading to EPN requiring emergency nephrectomy.

Case presentation: A 59-year-old type II tablet controlled diabetic woman presented complaining of a five day history of right sided abdominal pain associated with vomiting, abdominal distension and absolute constipation. There were no lower urinary tract symptoms. Past surgical history included an open appendectomy and an abdominal hysterectomy. On examination, she was haemodynamically stable, the abdomen was soft, distended, and tender in the right upper and lower quadrants with no bowel sounds. Investigations revealed a CRP of 365 and 2+ blood and nitrite positive on the urine dipstick. The AXR was reported as normal on admission, however when reviewed in retrospect revealed the diagnosis. She was managed, therefore, as having adhesional bowel obstruction and a simple UTI. After four days, a CT was organised as she was not settling. This showed a right pyohydronephrosis with gas in the collecting system secondary to an 8 mm obstructing ureteric calculus. The kidney was drained percutaneously via a nephrostomy and the patient was commenced on a broad spectrum intravenous antibiotics. Despite this, she went on to need an emergency nephrectomy for uncontrolled severe sepsis. She was discharged in good health 15 days later.

Conclusion: EPN carries a mortality of up to 40% with medical management alone. Early recognition of EPN in an obstructed kidney is essential to guide aggressive management, and in the presence of continued severe sepsis or organ dysfunction an urgent nephrectomy should be carried out. Diabetic patients who are known to have renal or ureteric calculi, whether symptomatic or not, should be considered for percutanous or ureteroscopic treatment. In the acute abdomen, the plain abdominal radiograph should always be viewed with respect to general surgical, vascular and urological differential diagnoses.

No MeSH data available.


Related in: MedlinePlus

CT scan showing an 8 mm calculi at the right PUJ.
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Figure 2: CT scan showing an 8 mm calculi at the right PUJ.

Mentions: The CT scan revealed a moderate hydronephrosis, with gas in a dilated pelvicalyceal system (Figure 1) due to an 8 mm stone at the right pelvi-ureteric junction (PUJ) (Figure 2). The right ureter was completely collapsed distal to the stone. Prompt urological input was sought, which lead to an immediate USS guided right nephrostomy with a 6-French catheter and frank pus was drained. Over the next 24 hours, the patient's condition deteriorated further, showing signs of severe sepsis with a compensated metabolic acidosis (pH 7.38, CO2 3.3 kPa, HCO3- 18 mmol/l, Base Excess -10 mmol/l, Lactate 8.6 mmol/l). In addition, the percutaneous nephrostomy was draining little urine, and thus an emergency right nephrectomy via a loin incision was performed after resuscitation and stabilization. Extraperitoneal dissection and excision of the kidney was technically challenging due to the acute timing of surgery, but proceeded without complication.


Emphysematous pyelonephritis in type II diabetes: A case report of an undiagnosed ureteric colic.

Vollans SR, Sehjal R, Forster JA, Rogawski KM - Cases J (2008)

CT scan showing an 8 mm calculi at the right PUJ.
© Copyright Policy - open-access
Related In: Results  -  Collection

License
Show All Figures
getmorefigures.php?uid=PMC2565667&req=5

Figure 2: CT scan showing an 8 mm calculi at the right PUJ.
Mentions: The CT scan revealed a moderate hydronephrosis, with gas in a dilated pelvicalyceal system (Figure 1) due to an 8 mm stone at the right pelvi-ureteric junction (PUJ) (Figure 2). The right ureter was completely collapsed distal to the stone. Prompt urological input was sought, which lead to an immediate USS guided right nephrostomy with a 6-French catheter and frank pus was drained. Over the next 24 hours, the patient's condition deteriorated further, showing signs of severe sepsis with a compensated metabolic acidosis (pH 7.38, CO2 3.3 kPa, HCO3- 18 mmol/l, Base Excess -10 mmol/l, Lactate 8.6 mmol/l). In addition, the percutaneous nephrostomy was draining little urine, and thus an emergency right nephrectomy via a loin incision was performed after resuscitation and stabilization. Extraperitoneal dissection and excision of the kidney was technically challenging due to the acute timing of surgery, but proceeded without complication.

Bottom Line: After four days, a CT was organised as she was not settling.Diabetic patients who are known to have renal or ureteric calculi, whether symptomatic or not, should be considered for percutanous or ureteroscopic treatment.In the acute abdomen, the plain abdominal radiograph should always be viewed with respect to general surgical, vascular and urological differential diagnoses.

View Article: PubMed Central - HTML - PubMed

Affiliation: Department of Urology, Huddersfield Royal Infirmary, Acre Street, Lindley, Huddersfield, HD3 3EA, UK. krogawski@doctors.org.uk.

ABSTRACT

Introduction: Emphysematous pyelonephritis (EPN) is a severe acute necrotising infection of the renal parenchyma and perirenal tissue, characterised by gas formation. 90% of cases are seen in association with diabetes mellitus. We report a case of undiagnosed ureteric obstruction in a type II diabetic, leading to EPN requiring emergency nephrectomy.

Case presentation: A 59-year-old type II tablet controlled diabetic woman presented complaining of a five day history of right sided abdominal pain associated with vomiting, abdominal distension and absolute constipation. There were no lower urinary tract symptoms. Past surgical history included an open appendectomy and an abdominal hysterectomy. On examination, she was haemodynamically stable, the abdomen was soft, distended, and tender in the right upper and lower quadrants with no bowel sounds. Investigations revealed a CRP of 365 and 2+ blood and nitrite positive on the urine dipstick. The AXR was reported as normal on admission, however when reviewed in retrospect revealed the diagnosis. She was managed, therefore, as having adhesional bowel obstruction and a simple UTI. After four days, a CT was organised as she was not settling. This showed a right pyohydronephrosis with gas in the collecting system secondary to an 8 mm obstructing ureteric calculus. The kidney was drained percutaneously via a nephrostomy and the patient was commenced on a broad spectrum intravenous antibiotics. Despite this, she went on to need an emergency nephrectomy for uncontrolled severe sepsis. She was discharged in good health 15 days later.

Conclusion: EPN carries a mortality of up to 40% with medical management alone. Early recognition of EPN in an obstructed kidney is essential to guide aggressive management, and in the presence of continued severe sepsis or organ dysfunction an urgent nephrectomy should be carried out. Diabetic patients who are known to have renal or ureteric calculi, whether symptomatic or not, should be considered for percutanous or ureteroscopic treatment. In the acute abdomen, the plain abdominal radiograph should always be viewed with respect to general surgical, vascular and urological differential diagnoses.

No MeSH data available.


Related in: MedlinePlus