EMPHYSEMATOUS PYELONEPHRITIS ASSOCIATED WITH PNEUMATOSIS INTESTINALIS AND BOWEL ISCHEMIA
Description
◉ Patient Background and Presentation:
• Age, Gender, and Ethnicity: Male African, 59 years old.
• Past medical history: No history of diabetes mellitus was revealed; the patient is known to have hypertension (not the typical diabetic EPN case).
▶ Chief complaints:
• left flank and left iliac pain that started abruptly and got worse over the course of a week.
• back pain that radiates posteriorly.
• Associated symptoms include dysuria, nausea, widespread exhaustion, and a high-grade temperature that reaches 39°C.
• Progression pattern: After days of increasing pain and systemic symptoms, an emergency visit was necessary.
▶ Results of the Physical Examination:
• Overall state: Although the patient seemed sick and poisoned, they were nevertheless focused and attentive.
Vital signs:
• Temperature: High fever that doesn't go away.
• Blood pressure: hypertension, 160/100 mmHg.
• 115 beats per minute (tachycardia).
• 22 breaths per minute (tachypnea).
▶ Local examination:
Tenderness in the left costovertebral angle is a sign of kidney infection or inflammation.
Tenderness in the left iliac region may be a sign of perinephric or pelvic extension.
The patient was able to voluntarily empty pee, indicating that there is no severe urinary retention.
▶ Initial Laboratory Investigations
• WBC count of 15,500/mm³ indicates leukocytosis, which is associated with an acute bacterial infection.
• 11.3 g/dL of hemoglobin indicates mild anemia, most often brought on by inflammation.
• Platelets: within normal norms, at 173,000/mm³.
• Acute kidney injury, most likely from sepsis or renal involvement, is indicated by a serum creatinine level of 2.18 mg/dL.
• Overall impression: renal failure accompanied by sepsis of urinary tract origin.
▶ First Clinical Course and Management:
• Empirical management:
• began using intravenous broad-spectrum antibiotics.
• aggressive intravenous fluid resuscitation to stabilize hemodynamics.
▶ Clinical decline:
• The patient experienced hemodynamic instability within hours of starting treatment.
• Hypotension and a persistent fever are indicators of the development of septic shock.
• In order to assess intra-abdominal reasons, urgent imaging was needed.
▶ Radiological Results:
• X-ray of the chest
• Finding: Pneumoperitoneum is indicated by the presence of air beneath the diaphragm.
• Interpretation: Indicates air tracks from an intra-abdominal illness or intestinal perforation.
• CT Abdomen – Without Contrast
▶ Kidney findings:
• The left kidney appears big and swollen.
• A hallmark sign of emphysematous pyelonephritis (EPN) is the presence of significant intrarenal and perinephric gas.
• Abscess formation due to accumulation of perinephric fluid.
• The mesentery and bowel:
• Inflammatory fat stranding and pneumatosis were observed in the mesentery of the descending colon.
• suggests necrosis or ischemia of the intestinal wall.
• Interpretation: An uncommon combination of intestinal and renal pathology suggests a serious infection that has progressed past Gerota's fascia.
• Abdomen CT Using IV and Oral Contrast
▶ Re-confirmation:
• persistent fluid and air accumulations in the perinephric space.
• Gas leakage into the peritoneal cavity is confirmed by small-to-moderate pneumoperitoneum.
• Bowel loops: Seem normally, however alterations in the descending colon are associated with inflammation in the mesenteric region.
▶ The diagnosis was made:
• left kidney emphysematous pyelonephritis (EPN).
• Intestinal pneumonia (PI) brought on by descending colon ischemia.
▶ Pathophysiological insights and discussion
• Gas development in the kidney, collecting system, or perinephric space is a sign of an advanced, necrotizing infection of the renal parenchyma and perinephric tissues, which is known as EPN.
▶ Pathogenesis:
• Mechanism of gas formation: Gas-forming microbes (mostly E. coli, Klebsiella, and Proteus) ferment glucose and tissue proteins.
▶ Conditions that predispose:
• elevated glucose levels in the tissue
• Anaerobic bacterial growth is favored by hypoxia due to poor tissue perfusion.
• weakened immune system and blockage of the urine.
• In this instance, a severe infection and vascular impairment created an environment that encouraged the development of gas, even though the patient did not have diabetes.
▶ The study of epidemiology
• More common in women and those with diabetes (70–90%).
• Proteus mirabilis, Klebsiella pneumoniae, and E. coli are common causal agents.
• Clinical challenge: Early diagnosis is challenging because EPN lacks particular indicators, such as fever, flank discomfort, dysuria, and sepsis.
Protocol
◉ Surgical Intervention and Findings:
• Due to probable ischemia bowel and peritonitis, an urgent open laparotomy was performed.
▶ Intraoperative results:
• The perinephric abscess was evacuated with gas and pus after Gerota's fascia (renal fascia) opened.
• The surgical drainage was deemed sufficient, and the left kidney was left in situ.
• Due to aberrant intestinal results, the general surgery team joined the procedure intraoperatively.
• A portion of the descending colon of about 10 cm was discovered to be inflammatory, necrotic, and ischemic.
• performed Hartmann's surgery (resection, end colostomy, and closure of the rectal stump) after performing resection of the afflicted segment.
▶ Management following surgery:
• ongoing intravenous antibiotics and supportive care in the intensive care unit.
• hemodynamics gradually stabilizing following surgery.
▶ Microbiological Outcomes:
• Klebsiella pneumoniae growth in blood and urine cultures.
• Pattern of antibiotic sensitivity: Vancomycin and ceftriaxone-sensitive organism.
◉ Nursing Interventions
▶ Preoperative Phase
• keeping an eye on neurological health and vital signs to spot early indicators of decline like disorientation and shock.
• keeping meticulous input and output records in order to evaluate fluid balance and renal function.
• ensuring that recommended IV fluids and medicines are administered on schedule in order to avoid care delays and worsening sepsis.
• reassure the patient and offer psychological support because of the severity of the symptoms.
▶ Intraoperative and Postoperative Care
• helping to prepare for emergency surgery while upholding aseptic standards and sterile technique.
• Infection prevention through postoperative surveillance for wound care, stoma management, and sepsis resolution.
• regular evaluation for issues such gastrointestinal problems, electrolyte abnormalities, and declining renal function.
• supporting nutritional requirements, promoting oral hydration where practical, and facilitating early mobilization.
▶ Education of Patients and Families:
• teaching the patient and their family about wound and stoma care, the significance of follow-up, and the warning signs and symptoms of infection recurrence.
• supplying consolation and open communication regarding the prognosis and processes.
▶ Problems Managed and Outcomes
• Rapid resuscitation, broad-spectrum antibiotics, and multidisciplinary surgical intervention were used to treat the potentially fatal infection, hemodynamic instability, and multi-organ involvement.
• Close observation, medication compliance, infection control, and patient support were all made possible by nursing interventions, and these factors greatly aided in the patient's recuperation and successful results.
• In this uncommon and serious instance, the recovery was greatly aided by the integrated nursing and medical care strategy, demonstrating the importance of alertness, prompt interventions, and interdisciplinary teamwork.
Notes
FOR MORE DETAILS VISIT: https://pmc.ncbi.nlm.nih.gov/articles/PMC8102767/?utm_source=chatgpt.com
