Brief ppt on emphysematous pyelonephritis

1. DR NAWAZ ALI
Emphysematous pyelonephritis

2. • Emphysematous pyelonephritis is a urologic emergency characterized by an
acute necrotizing parenchymal and perirenal infection caused by gas-forming
uropathogens.
• Pathogenesis poorly understood
• Because the condition usually occurs in patients with diabetes, it has been
postulated that the high tissue glucose levels provide the substrate for
microorganisms such as E. coli, which are able to produce carbon dioxide by the
fermentation of sugar

3. • Many patients have urinary tract obstruction associated with urinary calculi or
papillary necrosis and significant renal functional impairment.
• The overall mortality rate has been reported to be between 19% (Huang and
Tseng, 2000) and 43% (Freiha et al., 1979).

4. Clinical Presentation.
• Nearly all of the documented cases of emphysematous pyelonephritis have
occurred in adults (Hawes et al., 1983)
• Women are affected more often than men.
• The usual clinical presentation is severe, acute pyelonephritis.
• Almost all patients display the classic triad of fever, vomiting, and flank pain
(Schainuck et al., 1968).

5. • Pneumaturia is absent unless the infection involves the collecting system.
• Results of urine cultures are invariably positive.
• E. coli is most commonly identified. Klebsiella and Proteus spp. are less
common.
• Obstruction is demonstrated in approximately 25% of the cases.

6. Radiologic Findings.
• The diagnosis is established radiographically.
1. Plain X ray KUB:
• Tissue gas that is distributed in the parenchyma may
appear on abdominal radiographs as mottled gas shadows
over the involved kidney
• This finding is often mistaken for bowel gas.
• A crescentic collection of gas over the upper pole of the kidney is more
distinctive.
• As the infection progresses, gas extends to the perinephric space and
retroperitoneum.

7. 2. USG KUB:
• Demonstrates strong focal echoes suggesting the presence of intraparenchymal
gas
3. CT SCAN:
• CT is the imaging procedure of choice in defining the extent
of the emphysematous process and guiding management .
• An absence of fluid in CT images or the presence of streaky
or mottled gas with or without bubbly and loculated gas appears
to be associated with rapid destruction of renal parenchyma and
a 50% to 60% mortality rate
• The presence of renal or perirenal fluid, the presence of bubbly or
loculated gas or gas in the collecting system, and the absence of streaky
or mottled gas patterns are associated with a less than 20% mortality rate.
(Wan et al., 1996).

8. Huang and Tseng classification

9. Management.
• Emphysematous pyelonephritis is a urologic emergency.
• Most patients are septic, and fluid resuscitation, glucose and electrolyte
management, and broad-spectrum antimicrobial therapy are essential.
• Ureteral obstruction, if present, is alleviated by a percutaneous nephrostomy
tube or a stent
• Hypoalbuminemia, shock at initial presentation, bacteremia, indications for
hemodialysis, thrombocytopenia, altered mental status, and polymicrobial
infection are among various poor prognostic risk factors.

10. • Until the late 1980s, management involved emergency nephrectomy with or
without open surgical drainage and antibiotics ─ mortality of 40% to 50%
• Advancements in medicine, and definitive management by percutaneous
drainage decreases the mortality rate and
• Nephrectomy is indicated only in cases of extensive diffuse gas with renal
destruction.
• Early diagnosis and treatment of patients with diabetes and urinary infection is
important to potentially avoid progression of this disease process and in turn
nephrectomy

11. Thank you