A 59-year-old diabetic male presented to the emergency department with left-sided abdominal pain, abdominal distension, and decreased urine output over two days. Imaging revealed gas in the left renal calyces and retroperitoneal spaces, consistent with emphysematous pyelonephritis. The patient was admitted to the ICU for IV fluids, antibiotics, and glycemic control. A nephrostomy tube was placed and aspirated pus and air. Antibiotics were adjusted based on culture results identifying E. coli. The patient's condition improved with treatment and he was later discharged.

2.  A 59 year old diabetic male patient was
brought to the ED with chief complaints of
◦ left sided abdominal pain
◦ mild abdominal distension
◦ decrease urine output since 2 days and

3.  HR= 110
 Temp= 97
 BP= 100/60
 RR= 35
 SPO2= 92%
 CBG= 209

4.  Monitor shows sinus rhythm
 IV line inserted & blood drawn
 O2 via face mask

5.  Airway : patient speaking in full sentences
 Breathing: bl equal air entry present
 Circulation:pulses palpable at all sites ,Crt –N
 Disabality :GCS 15/15,puplis:reacting to light
& accommodation
 Exposure :no visible mass /rash /bleeding

6.  ECG
 ABG
 Pain management

7.  HOPI:As per pt .statement ,diffuse abdominal
pain sine 2-3 days but since 1 day pain has
increased in nature & intensity –persistent dull
pain without any aggravating or relieving factors
.Mild abdominal distention since 1 day &
decreased urine out put since one day
 Past medial & surgical history: Diabetic but not
on regular medication
 Allergic history: not allergic to any food or drugs
 Social history :married /non smoker ,non
alcoholic /family members in good health

8.  General examination :O+/d+
 HEENT- Normocephalic atraumatic
 ENT-N Trachea –C
 Chest :b/l equal air entry present
 CVS:S1S2 audible
 PA: Tense & tender whole abdomen: L lumbar
^ l hypochondriac ^ epigastrium ,IBS +
 CNS:No focal neurological deficit ,motor/
sensory -N

9.  SEPSIS
 PYELONEPHRITIS
 RENAL COLIC
 PANCREATITIS

10.  CBC
 S.electrolytes
 S.urea /creatinine
 LFT
 X ray chest
 Ct abdomen
 Urine RE/ME/CS
 PROCAL

11.  USG screening: in the ED revealed distension of the
major calyces and ureteric pelvis of the left kidney
 VBG= metabolic acidosis
Ph= 7.30, HCO3= 9.7, PCO2= 19.9

12.  CBC: Hb= 12, TLC= 15700, N= 84, Platlet count= 0.60
 Urea= 97, Creatinine= 3.2, K= 5.5
 Pro Cal > 75
 Urine examination:- Pus cells= 8-9/hpf, Bacteria
present, Blood= 2+, RBC= 10-12.
 .
 NCCT abdomen was planned

14.  NCCT Abdomen- revealed gas in the left renal
calyces and ureter suggestive of left sided
Emphysematous pyelonephritis and free air was
noted in retroperitoneal spaces.

15.  IV FLUIDS
 ANTIBIOTICS –MEROPENEM/METROGYL
 GLYCEMIC CONTROL

16.  patient was admitted in ICU with a diagnosis of
emphysematous pyelonephritis and severe sepsis.
 Next day USG guided Percutaneous Nephrostomy was done
and air and pus was aspirated.
 Gram staining of nephrostomy aspirate revealed gram
negative bacilli and culture showed E. Coli.

17.  Appropriate antibiotics was given as per the culture and
sensitivity reports.
 Insulin was added to control the diabetes and other
supportive care was given.
 Patient started recovering clinically and was discharged for
follow up in the urology department.

18.  Emphysematous pyelonephritis with severe sepsis if
recognized and treated early can be managed, so prompt
diagnosis and early treatment is crucial because of the high
rate of mortality.
 In high risk groups, such as diabetes presenting with upper
urinary tract infection the presence Emphysematous
pyelonephritis should be kept in mind
 Fever though the most common symptom of Emphysematous
pyelonephritis may be absent.

19. THANKS