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Treatment of a case of emphysematous pyelonephritis that presented with acute abdomen and pneumoperitoneum: a case report.

Park SH, Kim KH - BMC Nephrol (2015)

Bottom Line: Moreover, tissue necrosis and a perforation site were identified at the superior border of the right kidney.Hence, percutaneous drainage was performed.We believe that cases with free intraperitoneal air should promptly undergo laparotomy to identify the cause of the pneumoperitoneum.

View Article: PubMed Central - PubMed

Affiliation: Department of Urology, Inje University College of Medicine, Haeundae Paik Hospital, Busan, 612-896, Republic of Korea. urosh@inje.ac.kr.

ABSTRACT

Background: Emphysematous pyelonephritis is a severe, life-threatening infection of the renal parenchyma and perinephric tissues. This condition is primarily encountered in patients with diabetes mellitus or ureteral obstruction, and is characterized by the production of intrarenal and perinephric gas. Emphysematous pyelonephritis is associated with a high degree of morbidity and a high mortality rate.

Case presentation: A 72-year-old woman with a history of diabetes mellitus, hypertension, and renal calculi was referred to our emergency department following 6 days of abdominal pain. She suddenly developed pain in the entire abdomen, and was transferred. Physical examination was a distended abdomen with hypoactive bowel sounds. The tenderness was diffuse, but was most prominent in the right upper abdominal quadrant; moreover, rebound tenderness was noted. Laboratory tests revealed a white blood cell count of 4,480/mm(3), platelet count of 17,000/mm(3), creatinine level of 1.64 mg/dl, and serum glucose level of 603 mg/dl. Abdominal computed tomography indicated the presence of free air in the intraperitoneal cavity and right perirenal space, hydronephrosis of the right kidney, and stones in the right distal ureter. After 1 hour, the vital signs changed and she appeared to become drowsy. Therefore, the patient was transferred to the operation room for laparotomy. On exploration of the abdomen, 1.5 L of pus-colored fluid was removed. Although the abdominal viscera and pelvic organs were examined, hollow viscus perforation site could not be observed. Moreover, tissue necrosis and a perforation site were identified at the superior border of the right kidney. Thus, emphysematous pyelonephritis was diagnosed and she underwent right radical nephrectomy. After the surgery, the patient was admitted to the intensive care unit for postoperative management. Follow-up CT performed after 10 days showed fluid collection and hematoma at the nephrectomy site. Hence, percutaneous drainage was performed. Another follow-up computed tomography after 3 weeks indicated that the fluid collection at the nephrectomy site had nearly disappeared.

Conclusions: We believe that cases with free intraperitoneal air should promptly undergo laparotomy to identify the cause of the pneumoperitoneum. Moreover, an immediate nephrectomy may be effective for the treatment of emphysematous pyelonephritis in cases with poor prognostic factors.

No MeSH data available.


Related in: MedlinePlus

Abdominal CT finding. Axial view showing gas in the right renal parenchyme and perirenal space and intraperitoneal air (arrows)
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Fig1: Abdominal CT finding. Axial view showing gas in the right renal parenchyme and perirenal space and intraperitoneal air (arrows)

Mentions: A 72-year-old woman with a history of DM, hypertension, and renal calculi was referred to our emergency department following 6 days of abdominal pain. She was initially started on intravenous ciprofloxacin at another hospital; despite this treatment, her symptoms persisted and gradually exacerbated. She suddenly developed pain in the entire abdomen, and was therefore transferred to our hospital for further management. Her initial vital signs indicated a blood pressure of 140/90 mmHg, heart rate of 120 beats per minute, temperature of 37.9 °C, and respiratory rate of 20 breaths per minute. Physical examination on admission was a distended abdomen with hypoactive bowel sounds. The tenderness was diffuse, but was most prominent in the right upper abdominal quadrant; moreover, rebound tenderness was noted. Laboratory tests revealed a white blood cell count of 4,480/mm3 with 86 % granulocytes, hemoglobin level of 11.2 g/dl, platelet count of 17,000/mm3, creatinine level of 1.64 mg/dl, blood urea nitrogen level of 44.4 mg/dl, and serum glucose level of 603 mg/dl. Abdominal computed tomography (CT) indicated the presence of free air in the intraperitoneal cavity and right perirenal space, hydronephrosis of the right kidney, fluid and fat infiltration in the right perirenal space, and stones in the right distal ureter (Fig. 1). Hence, the patient was started on intravenous piperacillin-tazobactam plus ciprofloxacin, as well as fluid resuscitation on arrival. After 1 hour, the vital signs changed—the blood pressure decreased to 90/50 mmHg and temperature increased to 38.6 °C. Furthermore, she appeared to become drowsy. Therefore, the patient was immediately transferred to the operation room for laparotomy. On exploration of the abdomen, 1.5 L of pus-colored fluid was removed. Although the abdominal viscera and pelvic organs were examined, hollow viscus perforation site could not be observed. Moreover, tissue necrosis and a perforation site were identified at the superior border of the right kidney (Fig. 2). Thus, emphysematous pyelonephritis was diagnosed and she underwent right radical nephrectomy. During the surgery, the patient’s vital signs were unstable, and hence, vasopressin was intravenously administered. After the surgery, the patient was admitted to the intensive care unit for postoperative management. Norepinephrine was administered to maintain the blood pressure, and was tapered on postoperative day 2. The patient was weaned from ventilator support and extubated on postoperative day 4. Follow-up CT performed 10 days after the initial study showed fluid collection and hematoma at the nephrectomy site. Hence, percutaneous drainage was performed. Another follow-up CT after 3 weeks indicated that the fluid collection at the nephrectomy site had nearly disappeared. The patient was discharged to home in a stable condition, and was advised to attend follow-up visits at the surgery and nephrology departments.Fig. 1


Treatment of a case of emphysematous pyelonephritis that presented with acute abdomen and pneumoperitoneum: a case report.

Park SH, Kim KH - BMC Nephrol (2015)

Abdominal CT finding. Axial view showing gas in the right renal parenchyme and perirenal space and intraperitoneal air (arrows)
© Copyright Policy - open-access
Related In: Results  -  Collection

License 1 - License 2
Show All Figures
getmorefigures.php?uid=PMC4522122&req=5

Fig1: Abdominal CT finding. Axial view showing gas in the right renal parenchyme and perirenal space and intraperitoneal air (arrows)
Mentions: A 72-year-old woman with a history of DM, hypertension, and renal calculi was referred to our emergency department following 6 days of abdominal pain. She was initially started on intravenous ciprofloxacin at another hospital; despite this treatment, her symptoms persisted and gradually exacerbated. She suddenly developed pain in the entire abdomen, and was therefore transferred to our hospital for further management. Her initial vital signs indicated a blood pressure of 140/90 mmHg, heart rate of 120 beats per minute, temperature of 37.9 °C, and respiratory rate of 20 breaths per minute. Physical examination on admission was a distended abdomen with hypoactive bowel sounds. The tenderness was diffuse, but was most prominent in the right upper abdominal quadrant; moreover, rebound tenderness was noted. Laboratory tests revealed a white blood cell count of 4,480/mm3 with 86 % granulocytes, hemoglobin level of 11.2 g/dl, platelet count of 17,000/mm3, creatinine level of 1.64 mg/dl, blood urea nitrogen level of 44.4 mg/dl, and serum glucose level of 603 mg/dl. Abdominal computed tomography (CT) indicated the presence of free air in the intraperitoneal cavity and right perirenal space, hydronephrosis of the right kidney, fluid and fat infiltration in the right perirenal space, and stones in the right distal ureter (Fig. 1). Hence, the patient was started on intravenous piperacillin-tazobactam plus ciprofloxacin, as well as fluid resuscitation on arrival. After 1 hour, the vital signs changed—the blood pressure decreased to 90/50 mmHg and temperature increased to 38.6 °C. Furthermore, she appeared to become drowsy. Therefore, the patient was immediately transferred to the operation room for laparotomy. On exploration of the abdomen, 1.5 L of pus-colored fluid was removed. Although the abdominal viscera and pelvic organs were examined, hollow viscus perforation site could not be observed. Moreover, tissue necrosis and a perforation site were identified at the superior border of the right kidney (Fig. 2). Thus, emphysematous pyelonephritis was diagnosed and she underwent right radical nephrectomy. During the surgery, the patient’s vital signs were unstable, and hence, vasopressin was intravenously administered. After the surgery, the patient was admitted to the intensive care unit for postoperative management. Norepinephrine was administered to maintain the blood pressure, and was tapered on postoperative day 2. The patient was weaned from ventilator support and extubated on postoperative day 4. Follow-up CT performed 10 days after the initial study showed fluid collection and hematoma at the nephrectomy site. Hence, percutaneous drainage was performed. Another follow-up CT after 3 weeks indicated that the fluid collection at the nephrectomy site had nearly disappeared. The patient was discharged to home in a stable condition, and was advised to attend follow-up visits at the surgery and nephrology departments.Fig. 1

Bottom Line: Moreover, tissue necrosis and a perforation site were identified at the superior border of the right kidney.Hence, percutaneous drainage was performed.We believe that cases with free intraperitoneal air should promptly undergo laparotomy to identify the cause of the pneumoperitoneum.

View Article: PubMed Central - PubMed

Affiliation: Department of Urology, Inje University College of Medicine, Haeundae Paik Hospital, Busan, 612-896, Republic of Korea. urosh@inje.ac.kr.

ABSTRACT

Background: Emphysematous pyelonephritis is a severe, life-threatening infection of the renal parenchyma and perinephric tissues. This condition is primarily encountered in patients with diabetes mellitus or ureteral obstruction, and is characterized by the production of intrarenal and perinephric gas. Emphysematous pyelonephritis is associated with a high degree of morbidity and a high mortality rate.

Case presentation: A 72-year-old woman with a history of diabetes mellitus, hypertension, and renal calculi was referred to our emergency department following 6 days of abdominal pain. She suddenly developed pain in the entire abdomen, and was transferred. Physical examination was a distended abdomen with hypoactive bowel sounds. The tenderness was diffuse, but was most prominent in the right upper abdominal quadrant; moreover, rebound tenderness was noted. Laboratory tests revealed a white blood cell count of 4,480/mm(3), platelet count of 17,000/mm(3), creatinine level of 1.64 mg/dl, and serum glucose level of 603 mg/dl. Abdominal computed tomography indicated the presence of free air in the intraperitoneal cavity and right perirenal space, hydronephrosis of the right kidney, and stones in the right distal ureter. After 1 hour, the vital signs changed and she appeared to become drowsy. Therefore, the patient was transferred to the operation room for laparotomy. On exploration of the abdomen, 1.5 L of pus-colored fluid was removed. Although the abdominal viscera and pelvic organs were examined, hollow viscus perforation site could not be observed. Moreover, tissue necrosis and a perforation site were identified at the superior border of the right kidney. Thus, emphysematous pyelonephritis was diagnosed and she underwent right radical nephrectomy. After the surgery, the patient was admitted to the intensive care unit for postoperative management. Follow-up CT performed after 10 days showed fluid collection and hematoma at the nephrectomy site. Hence, percutaneous drainage was performed. Another follow-up computed tomography after 3 weeks indicated that the fluid collection at the nephrectomy site had nearly disappeared.

Conclusions: We believe that cases with free intraperitoneal air should promptly undergo laparotomy to identify the cause of the pneumoperitoneum. Moreover, an immediate nephrectomy may be effective for the treatment of emphysematous pyelonephritis in cases with poor prognostic factors.

No MeSH data available.


Related in: MedlinePlus