|Year : 2014 | Volume
| Issue : 1 | Page : 54-56
Extensive emphysematous pyelonephritis in association with hepatic portal venous gas and emphysematous gastritis: A rare case
Vikram Prabha1, Ritesh Vernekar2, Siddayya Hiremath1, JV Chethan1, Murigendra Hiremath3
1 Department of Urology, KLE University's JN Medical College Belgaum, Karnataka, India
2 Department of Nephrology, KLE University's JN Medical College Belgaum, Karnataka, India
3 PG Department of Studies in Biotechnology & Microbiology, Karnatak University, Dharwad, Karnataka, India
|Date of Web Publication||7-Feb-2014|
Department of Urology, KLES Kidney Foundation, KLES Dr. Prabhakar Kore Hospital and MRC, Belgaum - 590 010, Karnataka
Source of Support: None, Conflict of Interest: None
Although emphysematous pyelonephritis is recognized from more than hundred years, the etiology is still controversial. Glucose fermentation is the proposed possible mechanism for gas fermentation. The extension of emphysematous pyelonephritis into portal vein and stomach is a rare condition. We present a 52-year-old woman with uncontrolled diabetes who was admitted with sepsis and left flank pain. She was investigated, and results revealed gas in the left renal system with extension into portal vein and stomach. She was resuscitated and managed with percutaneous drainage, DJ stenting, and broad spectrum antibiotics, she did not improve and hence nephrectomy was done. Prompt diagnosis, early and aggressive treatment is crucial because of high mortality.
Keywords: Emphysematous gastritis, emphysematous pyelonephritis, portal vein gas
|How to cite this article:|
Prabha V, Vernekar R, Hiremath S, Chethan J V, Hiremath M. Extensive emphysematous pyelonephritis in association with hepatic portal venous gas and emphysematous gastritis: A rare case. J Sci Soc 2014;41:54-6
|How to cite this URL:|
Prabha V, Vernekar R, Hiremath S, Chethan J V, Hiremath M. Extensive emphysematous pyelonephritis in association with hepatic portal venous gas and emphysematous gastritis: A rare case. J Sci Soc [serial online] 2014 [cited 2019 Oct 13];41:54-6. Available from: http://www.jscisociety.com/text.asp?2014/41/1/54/126758
| Introduction|| |
Emphysematous pyelonephritis is an acute necrotizing parenchymal and perirenal infection caused by gas forming uropathogens. First case of emphysematous pyelonephritis was reported by Kelly and MacCallum in 1898.  Emphysematous pyelonehritis has variable clinical picture ranging from mild abdominal pain to severe sepsis leading to septic shock. The pathogenesis is poorly understood, it has been postulated that high tissue glucose levels provide substrate for microorganisms such as Escherichia More Details coli, which are able to produce carbon dioxide by fermentation of sugar.  But this explanation does not account for rarity of this disease despite the high frequency of Gram-negative urinary tract infection (UTI) in diabetic patients or does it explain the rare occurrence of this condition in non-diabetic patients.
In addition to diabetes, many patients have urinary tract obstruction associated with urinary calculi or papillary necrosis. It seems more reasonable to postulate that impaired host response caused by local factors such as obstruction, or a systemic condition such as diabetes, allows organisms with the capability of producing carbon dioxide to use necrotic tissue as a substrate to generate gas in vivo.
The overall mortality rate is between 19% and 43%. 
We report a rare case of poorly controlled diabetes with emphysematous pyelonehritis associated with emphysematous gastritis and air in portal vein.
| Case Report|| |
A 52-year-old female presented to our department with complaints of abdominal pain since 1 week. She was a known diabetic (poorly controlled). She was treated elsewhere in a local hospital and was referred for further management.
On examination, the patient had toxic look and appeared to be confused and slightly agitated. Vitals revealed temperature of 38.2°C, BP 120/70 mmHg, pulse rate of 120/min, respiratory rate of 22/min with saturation of 98% on room air. Physical examination revealed left sided costovertebral angle tenderness and tenderness in the gastric region.
Laboratory tests revealed white blood cell count (WBC) counts of 13,500/mm 3 , hemoglobin of 13, creatinine of 1.2 mg/dl. Urine analysis revealed plenty of WBCs. Ultrasound (US) examination of abdomen (which was done outside) revealed air in the collecting system suggestive of emphysematous pyelonephritis.
Computed tomography (CT) of abdomen (plain) revealed left sided emphysematous plelonephritis with air in the main portal vein and hepatic portal vein and also air in the wall of the stomach [Figure 1] and [Figure 2].
|Figure 2: CT KUB plain showing hepatic portal vein gas (small arrow) and gas in the stomach (big arrow)|
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Percutaneous catheter was placed for the drainage of Emphysematous pyelonehritis (EPN) and simultaneously DJ stenting was done. The patient was started on intravenous meropenem, amikacin, nasogastric decompression, and intravenous hydration. Total parenteral nutrition was started on day 2. Fever subsided but patient continued to have left flank pain and tachycardia (110/min). Follow up CT scan done on day 5 showed significant reduction in gas surrounding left kidney, but minimal gas persisted in portal vein and in the wall of stomach. Hence left nephrectomy was done. Intraoperatively, severe inflammation of the gerotas fascia with adhesion to the adjacent peritoneum was found, but there was no fistula formation between the infected kidney and gastrointestinal tract. She was kept nill by mouth with nasogastric decompression by ryles tube with adequate intravenous hydration for 4 days. E. coli was cultured from both blood and drainage. Same antibiotics, that is, meropenem and amikacin were continued. The patient recovered after 10 days and was discharged home in stable condition.
| Discussion|| |
The pathogenesis of EPN still remains unknown, however, four factors have been implicated, high tissue glucose levels (favoring bacterial growth), impaired tissue perfusion (leading to compromised oxygen delivery in the kidney) resulting in tissue ischemia and necrosis; nitrogen released during necrosis and a defective immune response due to impaired vascular supply. Intrarenal thrombi and renal infarctions have been claimed to be predisposing factors in nondiabetic patients. ,
Air in the portal vein or its radicals occurs when intraluminal or bacterial gas enters the porto-mesentric circulation. , Furthermore, portal vein gas occurs due to disruption of the bowel mucosa. Colonic involvement by inflammation tacking from pyelonephritis might occur.  Portal vein gas may be also through renal vein to portal vein collateral circulation under the ischemic environment of EPN.  Approach to the patient with portal venous gas should be directed to the underlying disease.  In our case, there was severe inflammation of the gerotas with adhesion of the adjacent peritoneum, we assume that the cause for portal gas was through this route.
Emphysematous gastritis is rare and may be secondary to local spread through the mucosa or rarely hematogenous dissemination from a distant focus. It is an uncommon disease due to abundant blood supply, acidic PH, and efficient mucosal barrier found in stomach.  Mainstay of treatment of emphysematous gastritis includes antibiotics, intravenous hydration, and supportive care. Surgery is indicated in complications like perforation. Prognosis is variable with a reported mortality rate of 60-80% despite early aggressive treatment.  In our case hematogenous dissemination is most likely the cause of emphysematous gastritis.
EPN is more common in women due to their increased susceptibility to UTIs. The left kidney was more frequently involved than the right one.  Patients with fulminating clinical course not responding to conservative measures nephrectomy should be considered for nephrectomy at the earliest.
| Conclusion|| |
Emphysematous pyelonephritis with portal vein gas and emphysematous gastritis is a very rare condition. To our knowledge this is first case reported in literature, which did not respond to conservative measures. Nephrectomy is the only option in such cases who fail conservative measures. Prompt diagnosis, early and aggressive treatment is crucial because of high mortality.
| References|| |
|1.||Huang Kelly HA, MacCallum WG. Pnuematuria. JAMA 1898;31:375-81. |
|2.||Schainuck LI, R Fouty, RE Cutler. Emphysematous pyelonephritis. A new case and review of previous observations Am J Med 1968;44:134-9. |
|3.||Huang JJ, Tseng CC. Emphysematous pyelonehritis: Cliniciradiological classification, management, prognosis, and pathogenesis. Arch Intern Med 2000;160:797-805. |
|4.||Shokier AA, El-Azab M, Mohsen T, El-Diasty T. Emphysematous pyelonephritis: 15 year experience with 20 cases. Urology 1997;49:343-6. |
|5.||Liebman PR, Patten MT, Manny J, Benfield JR, Hechtman HB. Hepatic-portal venous gas in adults: Etiology pathophysiology and clinical significance. Ann Surg 1978;187:281-7. |
|6.||Karaosmanoglu D, Oktar SO, Arac M, Erbas G. Case report: Portal and systemic venous gas in patients after lumbar puncture. Br J Radiol 2005;78:767-9. |
|7.||Burk I, Yeh BM, Joe BN, Qayyum A, Coakley FV. Pyelonephritis mimicking colitis on CT: Case report. Abdom Imaging 2005;30:105-7. |
|8.||Bashour CA, Popovich MJ, Irefin SA, Esfandiari S, Ratliff NB, Hoffman WD, et al. Emphysematous gastritis. Surgery 1998;123:716-8. |
|9.||Kussin SZ, Henry C, Navarro C, Stenson W, Clain DJ. Gas within the wall of stomach report of a case and review of literature. Dig Dis Sci 1982;27:949-54. |
[Figure 1], [Figure 2]