Rare differential diagnosis of acute lower abdominal pain – a case report of emphysematous cystitis
Tung-Ping Chang1, Thomas Y. Hsueh1,2, Yi-Jiun Hsiao1, Andy C. Huang1, Yu-Wei Lai1,2, Allen W. Chiu1,2
1. Department of Urology, Taipei City Hospital Ren Ai branch, Taipei, Taiwan
2. Department of Urology, National Yang-Ming University, Taipei, Taiwan
Emphysematous cystitis (EC) is a rare differential diagnosis in a patient with acute lower abdominal pain and potentially life-threatening form of complicated cystitis. Herein we present a case of EC in a 78-year old female with diabetes who had visited the emergency department twice in one day.
A 78-year-old woman with a history of type 2 diabetes mellitus, hypertension and chronic kidney disease presented to the emergency department twice with acute lower abdominal pain. Urinary analysis revealed pyuria with bacteriuria. The symptoms persisted despite the use of antibiotics and analgesics. Non-contrast abdominal computed tomography disclosed bladder wall thickening with intramural gas indicating emphysematous cystitis. Bladder drainage by Foley catheter was performed. Empirical antibiotics with cefuroxime were administered by intravenous injection and urine culture yielded Escherichia coli and Proteus mirabilis. The patient was discharged uneventfully 12 days later.
Emphysematous cystitis is potentially life-threatening and requires prompt diagnosis and treatment. Overall mortality rate of emphysematous cystitis is 7%. Risk factors include having diabetes, being female, a history of neurogenic bladder, obstructive uropathy and possibly immunosuppression.
Clinical features of EC are nonspecific and may vary individually. Immediate diagnosis and treatment is crucial because of the rapid progression to bladder necrosis, emphysematous pyelonephritis, urosepsis, and possibly fatal evolution. Computed tomography is the best modality for early diagnosis. Escherichia coli, K. pneumoniae and Enterobacter spp. are the most common bacteria isolated from urinary cultures. Most cases of emphysematous cystitis can be treated successfully with antibiotics, bladder drainage and correction of the underlying disorder.