Severe emphysematous pyelonephritis in diabetic patients: diagnosis and aspects of surgical management

PURPOSE: Emphysematous pyelonephritis (EPN) is a rare, severe gas-forming infection of renal parenchyma and surrounding tissues seen mostly in diabetic patients. Diagnosis and adequate therapeutic regimen are controversial. We reviewed the clinical presentation, diagnosis and aspects of surgical management of patients presenting with severe EPN. PATIENTS AND METHODS: Patients with EPN managed in our unit between 1996 and 2004 were reviewed. Diagnosis was confirmed by CT scan appearance of gas in the renal or perirenal area in a very ill patient. We compared the outcome of immediate nephrectomy with drainage of perinephric abscesses in patients presenting with severe EPN. RESULTS: Seven patients were managed in our unit during the 8-year period. All patients were diabetic and women outnumbered men (6:1). Renogram in all 7 patients showed renal function of affected kidney to be less than 15% in 6 patients. Escherichia coli was isolated in all patients from either urine, blood or perinephric pus. Management consisted of intensive resuscitation, control of blood glucose and use of intravenous antibiotics. Emergency nephrectomy was performed in 3 patients, delayed nephrectomy after an initial period of percutaneous drainage in 2 patients, incision and drainage in one patient and immediate percutaneous drainage was performed in one patient. One patient died 5 days post-nephrectomy of myocardial infarction. Patients who had immediate nephrectomy recovered quicker (18-21 days) and had no postoperative complications. Patients who had incision and drainage, or percutaneous drainage presented with recurrent discharging sinuses or perinephric abscesses requiring further surgical interventions and spent longer time in hospital (28-37 days). CONCLUSION: Patients with severe EPN often present in extremis and require intensive medical treatment. The diagnosis must be entertained in diabetic women presenting with flank pain and septicemia. The function of the affected kidney is often very poor and early nephrectomy offers the best outcome. Percutaneous drainage or incision and drainage of the abscess may be performed in patients too ill for immediate formal nephrectomy.     

Perinephric abscesses in the neurologically impaired

STUDY DESIGN: Retrospective chart review. OBJECTIVES: To document the occurrence and management of large perinephric abscesses in neurologically impaired patients at high risk for this infectious complication. SETTING: US Veterans Affairs hospital. METHODS: The records, radiographs, operative findings and outcomes of all patients who presented with perinephric abscesses evident on physical exam within the last 5 years were reviewed. RESULTS: Four patients presented with large perinephric abscesses evident on physical examination. All had severe neurologic impairment with high sensory levels; three had spinal cord injuries, one had advanced multiple sclerosis. All had neurogenic bladders and recurrent urinary tract infections. The diagnosis was made through a combination of history, physical examination and computed tomography (CT) examination. All were found to have upper tract obstruction. All were managed with immediate abscess drainage and three had elective nephrectomy once the infection had resolved. No patients died of their perinephric abscess. CONCLUSIONS: These four cases illustrate that although advances in antibiotics, imaging and percutaneous management have improved the speed of diagnosis and reduced the mortality in patients with perinephric abscesses, the neurologically impaired population continues to remain at significant risk for the development and the delayed diagnosis of these morbid renal infections.     

Renal and Perinephric Abscesses: Analysis of 65 Consecutive Cases

Objective The objective was to describe the last 10 years’ experience of the diagnosis and treatment of renal, perinephric, and mixed abscesses in an academic reference center. Patients and Methods The medical records of 65 patients with renal, perinephric, and mixed abscesses treated at our hospital from January 1992 to December 2002 were reviewed. The data collected included predisposing factors, symptoms, physical examination, initial diagnosis, laboratory and radiologic evaluation, treatment, and clinical outcome. Results Perinephric abscesses were found in 33 (50.8%) patients, renal abscesses were found in 16 (24.6%), and 16 (24.6%) had mixed abscesses. Urolithiasis (28%) and diabetes mellitus (28%) were the most common predisposing conditions. The duration of symptoms before hospital admission ranged from 2 to 180 days (mean 20 days). Urine culture was positive in 43% of patients and blood culture was positive in 40% of patients. Most of the perinephric abscesses received an interventional treatment: surgical drainage (24%), percutaneous drainage (42%) or nephrectomy (24%). Most patients were cured (73.3%) on discharge from hospital. Mixed (renal and perinephric) abscess treatment was similar: percutaneous drainage (37.5%), surgical drainage (18.75%) or nephrectomy (37.5%). Most patients were cured (60%) on discharge from hospital. Renal abscesses, however, were treated medically in 69% of patients and 73% were cured on discharge from hospital. Conclusions Perinephric and mixed abscesses are successfully managed by interventional treatment. Renal abscesses can be managed by medical treatment only, reserving interventional treatment for large collections or patients with clinical impairment. Early diagnosis is an important factor in the outcome of renal and perinephric abscesses.     

肾周脓肿25例的诊断与治疗

目的：提高肾周脓肿的诊断与治疗水平。方法：回顾性分析25例肾周脓肿患者的临床资料。结果：25例患者明确诊断为肾周脓肿，72％患者尿培养阳性，CT确诊率92％。3例(12％)死亡。10例患者脓肿直径1.8cm，单独使用抗生素治疗平均住院10d；11例脓肿平均直径11cm，采用抗生素联合经皮穿刺引流治疗，平均住院30d；4例最后进行了外科探查和肾切除。结论：肾周脓肿临床变化特点并不典型，CT检查是目前确诊最可靠的方法，通过明确的分期以获得理想的疗效。     

Percutaneous drainage of renal and perinephric abscesses

Two patients with renal or perinephric abscess were successfully managed by percutaneous drainage under ultrasonic guidance. We recommend percutaneous drainage as the first choice of treatment for a renal or perinephric abscess instead of traditional open surgery, especially in a high risk patient.     

The role of computed tomography in the diagnosis of renal and perirenal abscesses.

Computed tomography was done on 4 patients suspected of having an intrarenal or perirenal abscess based on clinical grounds and an abnormal excretory urogram. Intrarenal abscesses with perinephric extension were demonstrated in 3 patients and a solitary perinephric abscess was demonstrated in 1. Computed tomography is a valuable tool in the diagnostic study of suspected intrarenal and perirenal abscesses because not only can the primary abscess be shown but also its possible extrarenal extension.     

Retroperitoneal abscesses--analysis of a series of 66 cases

OBJECTIVE: To analyze our experience with the management of retroperitoneal abscesses. PATIENTS AND METHODS: A retrospective study was made of 66 patients with retroperitoneal abscesses treated at our hospital from January 1975 to July 2001 for the purpose of analyzing the diagnosis and treatment of these rare infections. In each case, we analyzed patient characteristics, abscess location and origin, predisposing factors, clinical presentation, microbiology, radiographic findings, treatment, and outcome. RESULTS: In our series, the most frequent type of abscess was perinephric (45.4%), and the most frequent origin was the kidney (72.7%), generally renal lithiasis or previous urological surgery. Gram-negative bacilli were the microorganisms most often involved as causal agents of abscesses. CT had the best diagnostic performance (95%). Percutaneous drainage resolved the abscess in 86.3% of the patients in which it was used, compared with 87.5% for traditional surgical drainage. In 4 cases, the only treatment was administration of antibiotics. In all these cases the abscesses were smaller than 3 cm and patients were in good general condition. The mortality rate was excellent (1.5%), probably due to the low rate of comorbidity in our patients. CONCLUSIONS: Gram-negative bacilli were the most frequent microorganisms in our retroperitoneal abscesses. CT was the imaging technique that produced the most reliable and rapid diagnosis. Radiographically-guided percutaneous drainage was a safe and effective therapeutic alternative when used as definitive treatment or preoperatively.     

Aspiration of breast abscess under ultrasound guidance: outcome obtained and factors affecting success

OBJECTIVE: To assess ultrasonographically (US) guided needle aspiration of breast abscesses as an alternative to surgical incision and drainage. METHODS: In our prospective study, 30 patients with 31 breast abscesses (one patient had bilateral breast abscess) underwent percutaneous breast abscess drainage under US guidance with local anaesthesia and oral antibiotics between 1 January 2004 and 31 March 2005. These patients consisted of 16 (53.3%) non-lactating and 14 (46.7%) lactating women, with ages ranging from 18 to 68 years (median, 28 years). The racial distribution comprised 26 (86.7%) Malays, three (10%) Chinese and one (3.3%) Indian. All patients had the chief complaint of breast swelling and 25 (83.3%) had breast pain. Clinically, 28 (93.3%) were found to have a palpable mass. Nine (30%) lesions were in the upper outer quadrant of the left breast. US diameters ranged from 1 to 15 cm (median, 4 cm). The pus volumes varied from 1 to 200 mL (median, 14 mL). RESULTS: Fifteen (50%) patients required only a single aspiration, 10 required multiple aspirations and five required incision and drainage. Those patients in whom needle aspiration failed had multiloculated lesions irrespective of abscess volume and size. CONCLUSION: Needle aspiration with ultrasound guidance is an effective treatment for breast abscess irrespective of abscess volume and size.     

Gas-forming infections in genitourinary tract.

Diabetes mellitus associated with urinary tract infections and ureteral obstruction can be predisposing factors leading to emphysematous pyelonephritis. Fever, flank pains, and a palpable renal mass, associated with dehydration and hyperglycemia, were the most frequent presenting symptoms associated with emphysematous pyelonephritis. Computerized tomography (CT) scan is the best method to identify a renal or perirenal abscess and its ramifications. Intravenous antibiotic therapy is determined by blood and urine cultures. Mortality was zero in patients treated by nephrectomy. One patient who had incision and drainage of a renal abscess died of sepsis, and 1 patient died of sepsis following incision and drainage of a prostatic abscess. Patients with cystitis emphysematosa require antibiotic therapy and relief of bladder outlet obstruction. Prostatic abscess is best treated by perineal incision and drainage. Periurethral scrotal abscesses should be incised, drained, and the overlying necrotic skin debrided. Early diagnosis and aggressive medical and surgical management of gas-forming infections of the genitourinary tract are vital.     

Diagnostic and treatment problems in renal injuries

The case records of 112 patients with 116 renal injuries seen at Detroit Receiving Hospital (July 1980 to June 1985) were reviewed. Eighty-three (74%) of the injuries were caused by gunshot wounds, 18 (16%) by stab wounds, and 11 (10%) by blunt trauma. Of 102 patients who had a urinalysis (U/A) in the Emergency Department (ED), 12 had a normal U/A. Five of these 12 patients had severe renal pedicle injuries. Of 75 excretory urograms (IVPs) performed preoperatively, 21 (28%) were normal including seven in patients with major renal injuries requiring surgical treatment. The incidence of shock was 38 per cent in patients with injuries not requiring renal explorations, 69 per cent in patients with renal parenchymal injuries requiring surgery, and 93 per cent in patients with pedicle injuries requiring repair or nephrectomy. Although it is generally believed that traumatic perirenal hematomas should not be explored, there was an increased incidence of complications with this approach in this series. Of 65 stable renal injuries treated conservatively (without exploration of the renal parenchyma), there were nine (14%) complications including three reoperation for missed injuries and three perinephric abscesses. In 46 injuries that were explored (38 for bleeding and eight without bleeding), there were only two complications (5%), including a perinephric abscess.     

PYOGENIC LIVER ABSCESS: A REVIEW OF 10 YEARS’ EXPERIENCE IN MANAGEMENT

Background : Over the past 15 years, diagnostic and interventional radiology techniques have allowed accurate localization of liver abscesses and image-guided percutaneous drainage. This review examines whether these technical advances improve clinical results and discusses the selection of treatment for patients with liver abscesses. Methods : Ninety-eight patients were treated for pyogenic liver abscess (PLA) at the Royal Prince Alfred Hospital, Sydney, between January 1987 and June 1997. The hospital records were examined and clinical presentation, laboratory, radiological and microbiological findings were recorded. Associations between these findings and failure of initial non-operative management were determined using odds ratios with 95% confidence intervals. Independent predictors were then determined by logistic regression. This analysis was repeated to determine factors associated with mortality. Results : Cholelithiasis and previous hepatobiliary surgery were the most frequently identifiable causes of PLA, each responsible in 15 patients. All 98 patients were treated with intravenous antibiotics and in 13 patients this was the only therapy. Of the remaining 85 patients, six proceeded straight to laparotomy and 79 had percutaneous drainage, of whom 15 required subsequent laparotomy. Factors predicting failure of initial non-operative management were unresolving jaundice, renal impairment secondary to clinical deterioration, multiloculation of the abscess, rupture on presentation and biliary communication. The overall hospital mortality rate was 8%. Conclusion : Pyogenic liver abscess remains a disease with significant mortality. Image-guided percutaneous drainage is appropriate treatment for single unilocular PLA. Surgical drainage is more likely to be required in patients who have abscess rupture, incomplete percutaneous drainage or who have uncorrected primary pathology.     

Right perinephric abscess: a rare presentation of ruptured retrocecal appendicitis

Perinephric abscess commonly arises from rup- ture of an intrarenal abscess into the perinephric space. It rarely results from gastrointestinal pathology. We report two pediatric patients with retrocecal appendicitis that presented with perinephric abscess. A 3-year-old girl presented with high fever and right flank pain for more than 1 week. Ultrasonography showed a right perinephric fluid collection with normal renal parenchyma and collecting system. A perinephric abscess extending from a ruptured retrocecal appendix was diagnosed by ab-dominal computed tomographic (CT) scan. Her hospital course was complicated with empyema, peritonitis, and pericardial effusion. A 6-year-old girl had lower abdominal pain for 3 days and high fever on the day of admission. Ultrasonography showed a right perinephric abscess with a normal renal contour and a fecalith in the enlarged appendix in the right lower quadrant of the abdomen. Appendectomy and drainage of the perinephric abscess were performed in both cases. We suggest that a ruptured retrocecal appendix must be considered in cases of perinephric abscess, especially in patients with gas bubbles in the abscess and a normal urogenital appearance. Ultrasonography and abdominal CT scan are the preferred diagnostic tools. Prolonged antibiotics and drainage of the abscess are mandatory to decrease morbidity and mortality. Received: 30 August 2001 / Reviesd: 15 November 2001 / Accepted: 17 November 2001     

非特异性肾周围炎及肾周围脓肿诊治分析（附20例报告）

目的：报道我院近五年来收治的20例肾周围炎及肾周围脓肿病例,并对其诊断和治疗作出分析。方法：回顾性分析了自2005年1月～2010年8月期间住院的20例肾周围炎及肾周围脓肿患者的病例资料。收集分析的资料包括：临床症状及体征、合并症、影像学检查、实验室检查、细菌培养、治疗及预后。结果：20例病例中,肾周围炎5例,肾周围脓肿15例。最主要的临床表现是腰腹部疼痛、发热、腰腹部肿块,分别为16例（80％）、12例（60％）、5例（25％）。另外少见临床表现有血尿3例（15％）、尿频尿急尿痛2例（10％）、恶心呕吐腹胀1例（5％）。合并症可见糖尿病、泌尿系结石、慢性肾盂肾炎、输尿管移行细胞癌、腹膜后纤维化及肾盂输尿管连接部狭窄,分别为5例（25％）、5例（25％）、7例（35％）、1例（5％）、1例（5％）、1例（5％）。有7例患者做血、尿、脓培养,其中5例阳性（71．4％）,致病菌主要为：大肠埃希菌、肺炎克雷白杆菌、变形杆菌,混合感染为2例（28．6％）。在所有患者中,单纯抗生素治疗者5例（25％）,B超引导下穿刺引流者6例（30％）（4例复发需再次手术,其中3例行切开引流,1例肾切除）,开放切开引流者5例（25％）,行。肾切除者4例（20％）。19例患者痊愈出院,1例患者形成窦道,迁延不逾,无死亡病例。结论：随着B超、CT等影像学技术的进步和普及,肾周围炎及肾周围脓肿的诊断和治疗已有较大的改善,尽早行彻底引流及有力的抗生素治疗是疾病痊愈的关键。     

Urinary tract and genito-urinary suppurative infections due to anaerobic bacteria

Anaerobes have been involved in many different types of urinary tract infection. This review describes the microbiology, diagnosis and management of urinary tract and genito-urinary suppurative infections caused by anaerobic bacteria. The types of infections of the urinary tract in which anaerobes have been involved include para- or periurethral cellulitis or abscess, acute and chronic urethritis, cystitis, acute and chronic prostatitis, prostatic and scrotal abscesses, periprostatic phlegmon, ureteritis, periureteritis, pyelitis, pyelonephritis, renal abscess, scrotal gangrene, metastatic renal infection pyonephrosis, perinephric abscess, retroperitoneal abscess and other infections. The anaerobes recovered in these studies were Gram-negative bacilli (including Bacteroides fragilis and pigmented Prevotella and Porphyromonas sp.), Clostridium sp., anaerobic Gram-positive cocci and Actinomyces sp. In many cases, they were recovered mixed with coliforms or streptococci. The recovery of anaerobes requires the administration of antimicrobial therapy that is effective against these organisms. These antimicrobials include metronidazole, chloramphenicol, clindamycin, a carbapenem, cefoxitin and the combination of a penicillin and a beta-lactamase inhibitor. Percutaneous drainage, open surgical drainage or nephectomy might be indicated for abscesses.     

Percutaneous management of pyogenic hepatic abscesses

Twelve patients (9 men, 3 women) with a mean age of 65 (54-78) years, with pyogenic hepatic abscesses were managed by percutaneous drainage between 1979 and 1987. Biliary origin was most common (4 patients), followed by hepatic abscesses as a late postoperative complication (seen in 3 patients) and hepatic abscesses occurring in association with acute appendicitis (2 patients). The origin was unknown in 3 patients. Diagnosis was reached by computed tomography or ultrasonography with a diagnostic delay of in mean 11 days. Seventeen abscesses were found among the 12 patients. The median abscess size (maximal diameter) was 7 (1-12) cm. Nine patients were treated with percutaneous drainage with an indwelling catheter within the abscess cavity for up to 3 weeks, while 3 patients were managed with percutaneous puncture and aspiration alone. The most commonly isolated organism from the drained hepatic abscess was E. coli. The course following percutaneous treatment was uneventful, without mortality and recurrence of the hepatic abscess during follow-up. One patient required surgical drainage of an additional hepatic abscess. Percutaneous drainage of hepatic abscesses, independent of origin, thus seems as a safe and reliable method, which should be considered as the treatment of choice if facilities and knowledge of percutaneous management are provided.     

Management of pyogenic liver abscess in the era of computed tomography

The advent of high-resolution imaging has allowed earlier diagnosis of pyogenic liver abscess. Because radiologically guided percutaneous drainage (PCD) of liver abscesses is controversial, the authors studied 40 patients with liver abscess admitted to the Toronto Hospital between 1982 and 1987 to determine the role of PCD versus operative drainage (OD). The diagnosis of pyogenic liver abscess was made at autopsy (4 patients), at laparotomy (6) or by radiologically guided aspiration of pus (30). Ultrasonography and computed tomography were highly sensitive (85% and 96% respectively) in detecting liver abscess. Of the 36 patients treated for liver abscess all received antibiotics intravenously; 31 also underwent a drainage procedure. Treatment with antibiotics alone was associated with a success rate of 80% and a death rate of 20%. The success rate for those who had PCD was 75% with a death rate of 13%; 2 patients in this group of 16 subsequently required OD for cure. In the 15 patients initially treated with OD, success and death rates were 87% and 13% respectively. For solitary abscesses, success rates wer comparable for PCD and OD (86% and 90% respectively). For unilobar multiple abscesses the success rate was 100% for both PCD and OD, but for bilobar multiple abscesses the rates were only 40% and 67% respectively. Complication rates were similar for both methods of drainage. The authors conclude that pyogenic liver abscess can now be safely and efficaciously managed with a combination of antibiotics and PCD.     

Pyogenic liver abscess: a review of 10 years' experience in management

BACKGROUND: Over the past 15 years, diagnostic and interventional radiology techniques have allowed accurate localization of liver abscesses and image-guided percutaneous drainage. This review examines whether these technical advances improve clinical results and discusses the selection of treatment for patients with liver abscesses. METHODS: Ninety-eight patients were treated for pyogenic liver abscess (PLA) at the Royal Prince Alfred Hospital, Sydney, between January 1987 and June 1997. The hospital records were examined and clinical presentation, laboratory, radiological and microbiological findings were recorded. Associations between these findings and failure of initial non-operative management were determined using odds ratios with 95% confidence intervals. Independent predictors were then determined by logistic regression. This analysis was repeated to determine factors associated with mortality. RESULTS: Cholelithiasis and previous hepatobiliary surgery were the most frequently identifiable causes of PLA, each responsible in 15 patients. All 98 patients were treated with intravenous antibiotics and in 13 patients this was the only therapy. Of the remaining 85 patients, six proceeded straight to laparotomy and 79 had percutaneous drainage, of whom 15 required subsequent laparotomy. Factors predicting failure of initial non-operative management were unresolving jaundice, renal impairment secondary to clinical deterioration, multiloculation of the abscess, rupture on presentation and biliary communication. The overall hospital mortality rate was 8%. CONCLUSION: Pyogenic liver abscess remains a disease with significant mortality. Image-guided percutaneous drainage is appropriate treatment for single unilocular PLA. Surgical drainage is more likely to be required in patients who have abscess rupture, incomplete percutaneous drainage or who have uncorrected primary pathology.     

Spontaneous nephrocutaneous fistula

Spontaneous renal fistula to the skin is rare. The majority of cases develop in patients with antecedents of previous renal surgery, renal trauma, renal tumors, and chronic urinary tract infection with abscess formation. We report the case of a 62-year old woman, who complained of urine leakage through the skin in the lumbar region for 2 years. She underwent a fistulography that revealed drainage of contrast agent to the collecting system and images suggesting renal lithiasis on this side. The patient underwent simple nephrectomy on this side and evolved without intercurrences in the post-operative period. Currently, the occurrence of spontaneous renal and perirenal abscesses is extremely rare, except in patients with diabetes, neoplasias and immunodepression in general.     

Pyogenic liver abscess. Diagnostic and therapeutic strategies.

A retrospective review of 26 adult patients admitted to University of California, Davis, Medical Center (UCDMC) with pyogenic liver abscess (1980-1986) was performed to ascertain the impact of rapid diagnosis and percutaneous drainage. Ultrasonographic examinations and computed tomography (CT) scans were highly sensitive and noninvasive imaging modalities. Sixteen patients had solitary abscesses and seven had multiple microscopic abscesses. The median time interval from admission to diagnosis and therapy was 2 and 3 days, respectively. Origin of the abscess was determined in 22 patients, the biliary tree being the most common source. Medical therapy was successful in three patients with microabscesses but failed in two. Nine patients had percutaneous drainage; two required repetitive percutaneous catheter placement, and two proceeded to surgical drainage. Twelve patients had surgical drainage; one required repetitive surgical drainage. Postdrainage complications were minimal in all groups. Overall mortality role was 11.5% (two patients). Deaths were related to delay in diagnosis, gram-negative sepsis at presentation, and biliary origin of the abscess.