- Email: [email protected]
Hepatic Portal Venous Gas Caused by Emphysematous Pyelonephritis
Image of the Month Hepatic Portal Venous Gas Caused by Emphysematous Pyelonephritis YAN–CHIAO MAO,* JIAAN– DER WANG,*,‡ and LEE–MING WANG* *Department of Emergency Medicine and ‡Department of Pediatrics, Taichung Veterans General Hospital, Taichung, Taiwan, Republic of China
A
56-year-old man with diabetes had a 3-week history of intermittent fever with left flank pain. On physical examination, a mass with marked tenderness was palpated over the left side of the abdomen. Laboratory data showed a white blood cell count of 1.0 ⫻ 109/L, platelet count of 108 ⫻ 109/L, C-reactive protein level of 22.4 mg/dL (normal range, ⬍0.3), and lactate level of 2.0 mmol/L (normal range, 0.3–1.3). Conventional radiograph imaging (Figure A) disclosed a huge air-containing lesion (arrow). Enhanced computed tomography scan (Figure B) revealed intraparenchymal gas (long arrow) and gas-forming abscess beneath renal capsule (short arrow) in association with gas at the periphery of Gerota’s fascia (arrowhead). Surprisingly, hepatic portal venous gas (HPVG) (arrow) was present in the imaging (Figure C), suggestive of emphysematous pyelonephritis (EPN) complicated with HPVG. The patient received percutaneous catheter drainage for EPN and later nephrectomy for nonfunctional kidney as well as broad-spectrum antibiotics treatment. Intraoperatively, severe inflammation of Gerota’s fascia with adhesion to adjacent peritoneum was found, but no fistula formation between destroyed kidney and gastrointestinal tract was explored. Escherichia coli were cultured from both blood and drainage. The patient uneventfully recovered 1 month later, and a follow-up computed tomography demonstrated complete resolution of HPVG. EPN occurs primarily in patients with diabetes or urinary tract obstruction, whereas HPVG mostly reflects disruption or necrosis of the bowel mucosa and is rarely associated with intra-abdominal abscess. Both of these entities are caused by the invasion of gas-forming organisms. To the best of our
knowledge, however, EPN concomitant with HPVG has never been reported. It is known that bacteria entry into portal vein through inflamed mesenteric venous bed from contiguous intra-abdominal abscess could lead to HPVG.1,2 Moreover, colonic involvement caused by inflammatory tracking from pyelonephritis might occur.3 Given the known factors predisposing patients to HPVG and bowel involvements observed from pyelonephritis, the case represents a probable cause of HPVG related with contiguous infection of EPN. In conclusion, HPVG is not a specific disease entity but merely a clue necessitating further evaluation in patients with acute abdomen. References 1. Moon CH, Doty C. Images in emergency medicine: emphysematous pyelonephritis. Ann Emerg Med 2006;48:354 –357. 2. Peloponissios N, Halkic N, Pugnale M, et al. Hepatic portal gas in adults: review of the literature and presentation of a consecutive series of 11 cases. Arch Surg 2003;138:1367–1370. 3. Burck I, Yeh BM, Joe BN, et al. Pyelonephritis mimicking colitis on CT: case report. Abdom Imaging 2005;30:105–107.
Conflicts of interest The authors disclose no conflicts. © 2009 by the AGA Institute 1542-3565/09/$36.00 doi:10.1016/j.cgh.2009.02.001 CLINICAL GASTROENTEROLOGY AND HEPATOLOGY 2009;7:xxv
A
56-year-old man with diabetes had a 3-week history of intermittent fever with left flank pain. On physical examination, a mass with marked tenderness was palpated over the left side of the abdomen. Laboratory data showed a white blood cell count of 1.0 ⫻ 109/L, platelet count of 108 ⫻ 109/L, C-reactive protein level of 22.4 mg/dL (normal range, ⬍0.3), and lactate level of 2.0 mmol/L (normal range, 0.3–1.3). Conventional radiograph imaging (Figure A) disclosed a huge air-containing lesion (arrow). Enhanced computed tomography scan (Figure B) revealed intraparenchymal gas (long arrow) and gas-forming abscess beneath renal capsule (short arrow) in association with gas at the periphery of Gerota’s fascia (arrowhead). Surprisingly, hepatic portal venous gas (HPVG) (arrow) was present in the imaging (Figure C), suggestive of emphysematous pyelonephritis (EPN) complicated with HPVG. The patient received percutaneous catheter drainage for EPN and later nephrectomy for nonfunctional kidney as well as broad-spectrum antibiotics treatment. Intraoperatively, severe inflammation of Gerota’s fascia with adhesion to adjacent peritoneum was found, but no fistula formation between destroyed kidney and gastrointestinal tract was explored. Escherichia coli were cultured from both blood and drainage. The patient uneventfully recovered 1 month later, and a follow-up computed tomography demonstrated complete resolution of HPVG. EPN occurs primarily in patients with diabetes or urinary tract obstruction, whereas HPVG mostly reflects disruption or necrosis of the bowel mucosa and is rarely associated with intra-abdominal abscess. Both of these entities are caused by the invasion of gas-forming organisms. To the best of our
knowledge, however, EPN concomitant with HPVG has never been reported. It is known that bacteria entry into portal vein through inflamed mesenteric venous bed from contiguous intra-abdominal abscess could lead to HPVG.1,2 Moreover, colonic involvement caused by inflammatory tracking from pyelonephritis might occur.3 Given the known factors predisposing patients to HPVG and bowel involvements observed from pyelonephritis, the case represents a probable cause of HPVG related with contiguous infection of EPN. In conclusion, HPVG is not a specific disease entity but merely a clue necessitating further evaluation in patients with acute abdomen. References 1. Moon CH, Doty C. Images in emergency medicine: emphysematous pyelonephritis. Ann Emerg Med 2006;48:354 –357. 2. Peloponissios N, Halkic N, Pugnale M, et al. Hepatic portal gas in adults: review of the literature and presentation of a consecutive series of 11 cases. Arch Surg 2003;138:1367–1370. 3. Burck I, Yeh BM, Joe BN, et al. Pyelonephritis mimicking colitis on CT: case report. Abdom Imaging 2005;30:105–107.
Conflicts of interest The authors disclose no conflicts. © 2009 by the AGA Institute 1542-3565/09/$36.00 doi:10.1016/j.cgh.2009.02.001 CLINICAL GASTROENTEROLOGY AND HEPATOLOGY 2009;7:xxv