經皮導管引流治療氣腫性腎盂腎炎：個案報告及文獻回顧

林瑞穎 劉冠麟 林政鋒 林承家 陳文祥 吳翊豪 楊昀達 陳鴻毅

基隆長庚醫院 外科部 泌尿科

Percutaneous drainage for management of emphysematous pyelonephritis

Jui-Ying Lin, Kuan-Lin Liu, Cheng-Feng Lin, Cheng-Chia Lin, Wen-Hsiang Chen, Yi-Hao Wu, Yun-Da Yang, Hong-Yi Chen

Divisions of Urology, Department of Surgery, Chang Gung Memorial Hospital, Keelung, Taiwan

Background:

Emphysematous pyelonephritis (EPN) is a severe acute necrotizing infection of the renal parenchyma and surrounding tissues that caused by the gas-forming uropathogens in the renal parenchyma, collecting system, or perinephric tissue and has a poor prognosis. EPN occurs primarily in people with diabetes mellitus (DM) because high tissue glucose levels provide the substrate for microorganisms, such as E. coli. In addition, many patients with EPN have urinary tract obstruction. The overall mortality rate has been reported to between 19% and 43%.

Case presentations:

We report the case of a 69-year-old woman with past history of type 2 DM, hypertension and hepatitis C virus carrier, presenting with vomiting and abdominal pain. Abdominal computed tomography (CT) scan revealed emphysematous pyelonephritis in left kidney. The urine culture was positive for E. coli. An 8Fr. Pigtail drain was placed by radiologist immediately. However, the patient’s condition did not improve after antibiotic treatment and percutaneous drainage (PCD). Revision of PCD was done with 10Fr. Pigtail on admission day 14. The patient was discharged on day 24 due to improving condition.

The patient returned to our emergency department 3 days after being discharged for dislodged pigtail. Abdominal CT showed regression of EPN with residual air. CT-guided drainage was performed and the patient was admitted to Nephrology ward for monitoring of renal function. During the admission, pigtail dislodge occurred and an urologist was consulted. Irrigation with normal saline was performed and patent function was noted. Observation was suggested. The patient was discharged on admission day12.

Discussion:

Broad-spectrum antibacterial agents were used as treatment of EPN. The Huang classification system is used to determine the treatment strategy for EPN. Recently, PCD is recommended for patients with less severe disease (class 1 or class 2) as well as severe disease (class3 or above). For patients who present with less severe disease, a single PCD is sufficient. However, patients who present severe disease combined with thrombocytopenia or more than two risk factors (acute renal failure, disturbance of consciousness, and shock) require repeated drainage procedure or even nephrectomy. The number of drain was one in cases who recovered, but two drains were more common in cases who underwent nephrectomy or died. This may be because emphysema is extensive in these severe patients, and therefore one drain might have been insufficient.

Conclusion:

Single PCD is effective in case with less severe EPN but less successful in patients with the combination of thrombocytopenia and Huang class 3 or above EPN, who require repeated drainage procedure. Nephrectomy or two drains are more common in severe cases of EPN. Besides, early management of EPN is important to reduce mortality rate.