Emphysematous Pancreatitis as a Life-Threatening Condition: A Case Report and Review of the Literature.

Emphysematous pancreatitis represents the presence of gas within or around the pancreas on the ground of necrotizing pancreatitis due to superinfection with gas-forming bacteria. This entity is diagnosed on clinical grounds and on the basis of radiologic findings. Computed tomography is the preferred imaging modality used to detect this life-threating condition. The management of emphysematous pancreatitis consists of conservative measures, image-guided percutaneous catheter drainage or endoscopic therapy, and surgical intervention, which is delayed as long as possible and undertaken only in patients who continue to deteriorate despite conservative management. Due to its high mortality rate, early and prompt recognition and treatment of emphysematous pancreatitis are crucial and require individualized treatment with the involvement of a multidisciplinary team. Here, we present a case of emphysematous pancreatitis as an unusual occurrence and discuss disease features and treatment options in order to facilitate diagnostics and therapy.

[Emphysematous cystitis: an uncommon cause of abdominal pain]. / Cistitis enfisematosa: una causa poco frecuente de dolor abdominal.

An 82-year-old woman with a previous medical history of hypertension and hypothyroidism was admitted to the emergency department for abdominal pain, diarrhea, confusion and changes in her overall condition over several days. At the emergency department, the patient was febrile and her blood tests showed elevated C-reactive protein without leukocytosis (8.9 × 10^9/L). In the current context, a nasopharyngeal swab for SARS was performed and was negative. With these results, the initial suspicion was that of an infectious condition of gastrointestinal origin. The urine sample was oul-smelling with presence of leukocytes and nitrites and was sent out for culture. In the setting of probable urinary tract infection, empirical antibiotic treatment was started with a third generation cephalosporin. It was decided to perform a total body scanner in order to evaluate the presence of other infectious foci. The study described the presence of emphysematous cystitis, a rare pathology in a patient without any of the classic risk factors for this entity. Urine and blood cultures were positive for Escherichia coli sensitive to the empiric antibiotic which was continued to complete 7 days. The clinical course was favorable.

Una mujer de 82 años con antecedentes de hipertensión arterial e hipotiroidismo acudió al servicio de urgencias por dolor abdominal, diarrea, confusión y deterioro de su estado general de varios días de evolución. A su admisión, la paciente se encontraba febril y la analítica mostró una elevación de la proteína C reactiva sin leucocitosis (8.9 × 10

[Bronchoscopic lung volume reduction]. / Endoskopische Lungenvolumenreduktion.

Bronchoscopic lung volume reduction is as a safe and effective therapy for patients with advanced emphysema, suffering from breathlessness despite optimal medical therapy. By reducing hyperinflation, it improves lung function, exercise capacity and quality of life. The technique includes one-way endobronchial valves, thermal vapor ablation and endobronchial coils. Patient selection is the key to a successful therapy; hence the indication should be evaluated in a multidisciplinary emphysema team meeting. The procedure can lead to a potentially life-threatening complication. Therefore, an adequate post-procedural patient management is crucial.

Indications for Percutaneous Drainage in Patients with Huang Class 3B Emphysematous Pyelonephritis: A Case Report and Literature Review.

Emphysematous pyelonephritis (EPN) is a severe urinary tract infection common in patients with diabetes. Nephrectomy is recommended when the Huang classification is ≥3B. We herein report a case in which nephrectomy was avoided using antimicrobial agents and percutaneous drainage (PCD). A 59-year-old man was diagnosed with EPN (Huang classification 3B). The causative bacteria were Escherichia coli. Despite high-risk factors, EPN was cured with kidney preservation and PCD because the emphysema and abscess were not extensive. Thus, PCD should be considered in patients with Huang Class 3B EPN and high-risk factors if emphysema and abscess are not extensive.

Emphysematous hepatitis with successful treatments: A rare case report.

RATIONALE: Emphysematous hepatitis (EH) is a rare and fulminant gas-forming liver infection. Only 3 patients were successfully treated. Diabetes mellitus and a history of digestive system cancer may predispose individuals to EH. Computed tomography (CT) findings support the diagnosis of EH and monitor progress. PATIENT CONCERNS: A 48-year-old man with diabetes presented with nausea, vomiting (gastric contents) and diarrhea. Laboratory test results revealed elevated levels of inflammatory indicators and abnormal liver function. CT showed a large-scale air collection with some remaining parenchymal debris in the left lobe of the liver. Remarkably, no fluid was observed inside the lesion. DIAGNOSE: The abdominal CT features and laboratory examination results rationalized the diagnosis of EH. INTERVENTIONS AND OUTCOMES: The patient finally recovered from this severe disease through a series of effective treatments, including strict glucose control, sensitive antibiotic therapy, and subsequent percutaneous drainage. LESSONS: EH generally deteriorates rapidly and eventually leads to death. This case will raise awareness of the rare and severe disease, strengthen diagnostic capacities, and provide advice to treat it.

Emphysematous cystitis: an incidental finding with varying outcomes.

Emphysematous cystitis (EC) is a rare severe urinary tract infection characterised by pockets of air in and around the urinary bladder wall caused by gas-forming organisms. Common predisposing factors are chronic infection, immunosuppression, diabetes and neurogenic bladder. The presentation may vary from mild illness to severe life-threatening cystitis. We report two cases of incidental detection of EC diagnosed on imaging for the evaluation of unrelated symptoms. Although asymptomatic, this lethal disease still warrants prompt recognition and treatment with broad-spectrum antibiotics and urinary bladder drainage to prevent severe morbidity and mortality.

Venous gas caused by emphysematous pyelonephritis: a case report and review of literature.

BACKGROUND: Emphysematous pyelonephritis (EPN) is a potentially life-threatening disease caused by a gas-producing necrotizing bacterial infection that involves the renal parenchyma, collecting system, and/or perinephric tissue. EPN is often complicated by a previous diagnosis of diabetes mellitus, and venous air bubbles are an uncommon complication of it. We describe a 52-year-old woman who was admitted in coma, with a history of vomiting, and was found to have EPN with air bubbles in the uterine veins. We discuss the presentation, diagnosis, and pathogenesis of this uncommon but clinically significant event, and briefly review other case reports of venous gas or thrombosis caused by EPN. CASE PRESENTATION: We report the case of a 52-year-old woman with past history of type 2 diabetes mellitus, presenting with loss of consciousness after vomiting for half a day. Abdominal computed tomography scan revealed unilateral EPN with air bubbles in the uterine veins. The blood, pus, and urine cultures were positive for extended-spectrum beta-lactamase-producing Escherichia coli. The patient's condition improved well after conservative management comprising supportive measures, broad-spectrum antibiotics, percutaneous drainage therapy, and an open operation. CONCLUSIONS: Venous air bubbles are rare but fatal complication of EPN. Early diagnosis and treatment are critical to ensure good results.

[Emphysematous gastritis. Report of a case in the elderly]. / Gastritis enfisematosa. Reporte de un caso en el adulto mayor.

Introduction: Emphysematous gastritis is an uncommon pathology but with high mortality, its clinical presentation is insidious, the tomography image is distinguished by a pattern of linear bubbles with thickening of the gastric wall. Background: This is a 78-year-old male, previously healthy, functional, who was admitted for pertrochanteric fracture of the left hip, who during hospitalization presented hyperactive delirium, abdominal distention with decreased perstalsis in addition to arterial hypotension, an abdominal tomography with evidence of gastric dilation and multiple air bubbles in the wall. He is managed with a broad spectrum antibiotic, fluid therapy and parenteral nutrition, with a favorable response. Conclusions: Advanced age does not in itself lead to a worse disease prognosis, the evidence supports that early diagnosis and early therapeutic intervention are the measures that have proven to be more effective in reducing mortality in patients with emphysematous gastritis.

Introducción: la gastritis enfisematosa es una patología poco común pero con alta mortalidad, su presentación clínica es insidiosa, la imagen por tomografía se distingue por un patrón de burbujas lineales con engrosamiento de la pared gástrica. Caso clínico: paciente masculino de 78 años, previamente sano, funcional, que fue ingresado por fractura pertrocantérica de cadera izquierda, quien durante la hospitalización presenta delirium hiperactivo, distención abdominal con disminución de perístalsis además de hipotensión arterial, se realiza tomografía abdominal con evidencia de dilatación gástrica y múltiples burbujas de aire en pared. Es manejado con antibiótico de amplio espectro, fluidoterapia y nutrición parenteral, con respuesta favorable. Conclusiones: la edad avanzada no conlleva por sí misma un peor pronóstico de la enfermedad, la evidencia apoya que un diagnóstico precoz y la intervención terapéutica temprana, son las medidas que han demostrado ser efectivas para la disminución de la mortalidad en pacientes con gastritis enfisematosa.

Gastritis enfisematosa. Reporte de un caso en el adulto mayor / Emphysematous gastritis. Report of a case in the elderly

Introducción: la gastritis enfisematosa es una patología poco común pero con alta mortalidad, su presentación clínica es insidiosa, la imagen por tomografía se distingue por un patrón de burbujas lineales con engrosamiento de la pared gástrica. Caso clínico: paciente masculino de 78 años, previamente sano, funcional, que fue ingresado por fractura pertrocantérica de cadera izquierda, quien durante la hospitalización presenta delirium hiperactivo, distención abdominal con disminución de perístalsis además de hipotensión arterial, se realiza tomografía abdominal con evidencia de dilatación gástrica y múltiples burbujas de aire en pared. Es manejado con antibiótico de amplio espectro, fluidoterapia y nutrición parenteral, con respuesta favorable.Conclusiones: la edad avanzada no conlleva por sí misma un peor pronóstico de la enfermedad, la evidencia apoya que un diagnóstico precoz y la intervención terapéutica temprana, son las medidas que han demostrado ser efectivas para la disminución de la mortalidad en pacientes con gastritis enfisematosa

Introduction: Emphysematous gastritis is an uncommon pathology but with high mortality, its clinical presentation is insidious, the tomography image is distinguished by a pattern of linear bubbles with thickening of the gastric wall.Background: This is a 78-year-old male, previously healthy, functional, who was admitted for pertrochanteric fracture of the left hip, who during hospitalization presented hyperactive delirium, abdominal distention with decreased perstalsis in addition to arterial hypotension, an abdominal tomography with evidence of gastric dilation and multiple air bubbles in the wall. He is managed with a broad spectrum antibiotic, fluid therapy and parenteral nutrition, with a favorable response.Conclusions: Advanced age does not in itself lead to a worse disease prognosis, the evidence supports that early diagnosis and early therapeutic intervention are the easures that have proven to be more effective in reducing mortality in patients with emphysematous gastritis.

Predictive factors for mortality and intensive care unit admission in patients with emphysematous pyelonephritis: 5-year experience in a tertiary care hospital.

INTRODUCTION AND OBJECTIVES: Emphysematous pyelonephritis is a life-threatening infection of the kidney and surrounding tissues associated with a high mortality rate. The aim of this study was to determine predictive factors for mortality and intensive care unit admission in patients with emphysematous pyelonephritis, and to propose a therapeutic algorithm based on current literature and our experience. METHODS: A retrospective study was done including patients with emphysematous pyelonephritis in a single center in the north of Mexico from 2011 to 2016. Demographic, clinical, microbiological and biochemical parameters, therapeutic management, and outcomes were assessed. Factors associated with admission to intensive care unit and mortality were determined. Comparison was assessed using X2 test for categorical variables, and T-test for numerical variables. Univariate and multivariate logistic regression analyses were performed. Statistical significance was set at P < .05. RESULTS: A total of 63 patients were included, of which 55 (87.3%) were females, with a mean age of 55.5 ±â€¯12.2 years. The most common comorbidities were diabetes and hypertension. Escherichia coli was the most common isolated microorganism (51.7%) and extended-spectrum beta-lactamase-producing agents were reported in 31.7%. Conservative therapy was provided to 38.7%, double J stent 42.9%, open/percutaneous drainage 12.7%, and nephrectomy 25.3%. Overall mortality and intensive care admission were 20.6% and 36.5%, respectively. In the multivariate analysis, hemodynamic instability (P = .005), qSOFA ≥ 2 (P = .003), hypoalbuminemia (P = .02), and early nephrectomy (P = .002) were associated with intensive care admission. Huang scale 4 (P = .006) and early nephrectomy (P = .001) were associated to mortality. CONCLUSIONS: Emphysematous pyelonephritis is a life-threatening disease and evidence of management is based in small case series due to the low incidence of this condition. Hemodynamic instability, hypoalbuminemia, qSOFA ≥ 2, Huang scale ≥3, and early nephrectomy are associated with poor prognosis.

A systematic review and meta-analysis of risk factors and treatment choices in emphysematous pyelonephritis.

PURPOSE: Emphysematous pyelonephritis (EPN) is an acute, severe necrotising infection of the kidney. There has been a shift from early nephrectomy to conservative methods. We conducted a meta-analysis to assess the impact of risk factors and treatment choices on outcomes in EPN. METHODS: We conducted a database search of all studies in English, reporting more than 12 patients of EPN from 1980 to 2020. We compiled the demographics, clinical presentations, risk factors, critical diagnostic results, treatment modalities and outcomes, including mortality. RESULTS: We identified 37 observational studies, 32 retrospective and 5 prospective. The studies reported on 1146 patients, of which 790(68.9%) were female, and 946 (82.5%) were diabetic. In addition, 184 (16.1%) patients had stones, and 235 (20.5%) had obstructive uropathy. Fever and flank pain were the most frequent symptoms. The most common clinical features were pyuria, fever, flank tenderness, and tachycardia. E. coli, Klebsiella pneumoniae and Proteus were the most frequent organisms isolated. X-ray KUB and ultrasound were used as initial diagnostic modalities, but CT scan was the usual diagnostic and confirmatory investigation. Confusion, shock, thrombocytopenia, sepsis, emergency nephrectomy and hyponatremia were significantly associated with mortality. In particular, confusion and hyponatremia were associated with a sevenfold increase in mortality risk. There was no evidence that diabetes, stones, obstructive uropathy, AKI or proteinuria was associated with higher mortality. Nevertheless, 143 of the total 1146 patients died (12.5%). While 26% of the patients who had upfront emergency nephrectomy died, only 9.7% and 10% of patients with medical management and medical management plus minimally invasive treatments died. However, patients that failed medical and minimally invasive treatments and needed salvage emergency nephrectomy had a mortality of upwards of 27%. CONCLUSION: The risk factors for mortality in emphysematous pyelonephritis are shock, thrombocytopenia, confusion, hyponatremia and emergency nephrectomy. Conservative and minimally invasive treatment should be the initial management strategy for emphysematous pyelonephritis as they carry lesser mortality risks. The presence of risk factors may help predict the subset of patients who need aggressive treatment and minimally invasive treatment modalities or early nephrectomy.

[Diagnosis and treatment for emphysematous pyelonephritis: analysis of 14 cases from a single centre].

Objective: To examine the modalities of treatment and clinical outcomes of emphysematous pyelonephritis (EPN), in order to improve the survival rate of EPN patients. Methods: Totally 14 patients diagnosed as EPN between October 2011 and November 2020 at Department of Urology, Sir Run Run Shaw Hospital, Zhejiang University School of Medicine were included in this article. Data collection including patient demographics, clinical manifestations, management and clinical outcomes were conducted by retrospective charts review, after receiving the institutional review board's approval. There were 11 females and 3 males with a median age of 59 years (range: 52 to 73 years). The lesions were located on the left side in 10 patients and right side in 4 patients. All the 14 patients suffered from fever, and present with severe sepsis or septic shock. The median time from symptom onset to admission to hospital was 3 days(range: 2 to 5 days). All cases had diabetes mellitus. Escherichia coli was the most common organism been cultured (11 cases), while Klebsiella pneumonia was the second (3 cases). CT scan showed bubbly or located gas in the renal parenchyma in 5 cases and presence of steaky or mottled gas in the renal parenchyma in 9 cases. All patients had been admitted to ICU for anti-septic shock therapy. Three patients had undergone percutaneous catheter drainage along with broad-spectrum antibiotics therapy while 3 patients had immediate nephrectomy, the other 8 cases had a combination of an initial percutaneous catheter drainage and second stage nephrectomy. Results: In this case series, 3 patients were died from EPN while the other 11 were survived. The median ICU stay time was 6 days (range: 3 to 11 days). Of the 3 patients died from EPN, 2 had undergone percutaneous catheter drainage along and 1 had received immediate nephrectomy. Among the 11 patients who were survived, only 1 had received percutaneous catheter drainage while the other 10 received nephrectomy (8 patients had staged nephrectomy). Follow-up was performed 6 months after discharge. Of the 11 surviving patients, 2 were lost to follow-up, and the remaining 9 patients had an creatine level of (118.4±29.4) µmol/L (range: 89 to 176 µmol/L). Conclusions: For patients coupled with diabetes who were initially diagnosed as acute pyelonephritis, the possibility of EPN should be considered when the disease progressed rapidly especially septic shock occurred. On the basis of empirical broad-spectrum antibiotics therapy and standardized anti-septic shock treatment, a combination of an initial percutaneous catheter drainage and second stage nephrectomy could be efficacious.

Acute emphysematous cholecystitis due to clostridium perfringens: a rare entity requiring aggressive and early treatment.

Acute emphysematous cholecystitis is a rare entity (1% of acute cholecystitis) characterized by the presence of gas in the gallbladder lumen, gallbladder wall or even in the bile duct (pneumobilia). It is associated with arteriosclerosis, embolic events, and diabetes mellitus and as in other similar pathologies such as emphysematous gastritis or emphysematous pancreatitis the most frequently isolated microorganisms are Streptococcus pyogenes, Escherichia coli and Staphylococcus aureus, although others such as Proteus vulgaris, Pseudomonas aeruginosa, Clostridium perfringens and Klebsiella pneumoniae have also been found.

Emphysematous pyelonephritis caused by C. glabrata.

Emphysematous pyelonephritis (EPN) is a rare acute necrotizing infection of the kidney and surrounding tissues, with gas in the renal parenchyma, collecting system or perirenal tissue. The bacterial etiology predominates; mainly Gram-negative bacilli; Candida spp. and C. albicans are rarely described. We describe a case of EPN caused by C. glabrata, sensitive to fluconazole in a young, hypertensive woman with undiagnosed diabetes mellitus (DM), with renal dysfunction upon admission; her abdominal CT scan found a volumetric increase in the left kidney, signs of gas collections and perirenal blurring. Despite the antimicrobial therapy instituted, due to clinical refractoriness, a double J catheter and subsequent total nephrectomy were indicated, with good postoperative evolution. Her uroculture showed C. glabrata sensitive to fluconazole, and the pathology study showed tubular atrophy and intense interstitial inflammatory infiltrate. Despite the serious, potentially fatal condition, we could control the infection and the patient recovered fully. Poor DM management is an important triggering factor, and it is of great relevance to identify the EPN through imaging exams due to the peculiarities of its clinical and potentially surgical management.

Diagnosis and treatment for emphysematous pyelonephritis: analysis of 14 cases from a single centre / 中华外科杂志

Objective: To examine the modalities of treatment and clinical outcomes of emphysematous pyelonephritis (EPN), in order to improve the survival rate of EPN patients. Methods: Totally 14 patients diagnosed as EPN between October 2011 and November 2020 at Department of Urology, Sir Run Run Shaw Hospital, Zhejiang University School of Medicine were included in this article. Data collection including patient demographics, clinical manifestations, management and clinical outcomes were conducted by retrospective charts review, after receiving the institutional review board's approval. There were 11 females and 3 males with a median age of 59 years (range: 52 to 73 years). The lesions were located on the left side in 10 patients and right side in 4 patients. All the 14 patients suffered from fever, and present with severe sepsis or septic shock. The median time from symptom onset to admission to hospital was 3 days(range: 2 to 5 days). All cases had diabetes mellitus. Escherichia coli was the most common organism been cultured (11 cases), while Klebsiella pneumonia was the second (3 cases). CT scan showed bubbly or located gas in the renal parenchyma in 5 cases and presence of steaky or mottled gas in the renal parenchyma in 9 cases. All patients had been admitted to ICU for anti-septic shock therapy. Three patients had undergone percutaneous catheter drainage along with broad-spectrum antibiotics therapy while 3 patients had immediate nephrectomy, the other 8 cases had a combination of an initial percutaneous catheter drainage and second stage nephrectomy. Results: In this case series, 3 patients were died from EPN while the other 11 were survived. The median ICU stay time was 6 days (range: 3 to 11 days). Of the 3 patients died from EPN, 2 had undergone percutaneous catheter drainage along and 1 had received immediate nephrectomy. Among the 11 patients who were survived, only 1 had received percutaneous catheter drainage while the other 10 received nephrectomy (8 patients had staged nephrectomy). Follow-up was performed 6 months after discharge. Of the 11 surviving patients, 2 were lost to follow-up, and the remaining 9 patients had an creatine level of (118.4±29.4) μmol/L (range: 89 to 176 μmol/L). Conclusions: For patients coupled with diabetes who were initially diagnosed as acute pyelonephritis, the possibility of EPN should be considered when the disease progressed rapidly especially septic shock occurred. On the basis of empirical broad-spectrum antibiotics therapy and standardized anti-septic shock treatment, a combination of an initial percutaneous catheter drainage and second stage nephrectomy could be efficacious.

[Clinical characteristics of five patients with gastric emphysema].

Gastric emphysema is a rare condition in which gas from a nonbacterial source accumulates within the gastric wall. In this study, we retrospectively analyzed the cases of five patients who were diagnosed with gastric emphysema at the Okayama University Hospital between January 2010 and April 2021, to reveal the clinical features of the disease. Based on their reviews, we revealed that:i) gastric emphysema occurred in hospitalized bedridden patients (n=5), such as those during/after endotracheal intubation (n=3), those undergoing gastric tube placement (n=3), those undergoing percutaneous endoscopic gastrostomy (n=1), and those undergoing treatment for cerebral infarction (n=1);ii) gastric emphysema was accompanied by the accumulation of gas in the portal (n=4) or gastric veins (n=1);iii) gastric emphysema was accompanied by colon wall thickness increase (n=4);iv) esophagogastroduodenoscopy showed redness, erosions, coarse mucosa, and/or ulcers (n=5);v) a clear boundary between the damaged area and the intact mucosa was observed (n=5);vi) the anterior wall of the stomach was less affected (n=4);vii) mucosal damage was predominant in the gastric folds, whereas the furrow of the mucosa was less affected;and viii) treatment with enteral nutrition suspension and the administration of proton pump inhibitors and antibiotics resulted in the recovery of patients from gastric emphysema (n=5). These results indicate that patients with gastric emphysema have distinct clinical, endoscopic, and radiological features. Furthermore, our results show that these patients can be conservatively managed.

[Emphysematous cystitis and emphysematous pyelonephritis]. / Cistitis y pielonefritis enfisematosa.

Emphysematous cystitis and emphysematous pyelonephritis are rare entities, difficult to diagnose and with high morbidity and mortality. The non-specificity of the medical history and the little usefulness of laboratory tests contribute to diagnostic delay, which increases the possibility of therapeutic failure. We present 2 cases, one of cystitis and another of emphysematous pyelonephritis, who attended the emergency room due to severe urinary sepsis. Despite severity of the symptoms, conservative management was performed with bladder drainage and antibiotic treatment, without interventions or surgeries, presenting a favorable evolution and resolution of the infectious process. Each case must be individualized to offer the best possible therapeutic alternative.