The Bounceback

[DD]

40 year old male presents with lower abdominal pain, nausea, vomiting, and diarrhea that started 3 hours ago. He states it started while he was watching a movie and he had to go to the bathroom 5 times. He is upset that he missed the movie and asks you if you had seen it. He denies any trauma, chest pain, SOB, fever, headache, weakness, or similar pain in the past. When asked where the pain is he points to his LLQ and states it wraps across.

PMHX: Psychiatric issues. HTN.

PSHX: Appendectomy.

Meds: One blood pressure, rest psych.

Exam: AA&Ox3, NAD, vitals: 130/60, 80 bpm, 98 degrees, 18 resp, 100% RA.
CVS, Chest, neuro, ENT, back: WNL.
Skin: Multiple small lesions on the bilateral legs that appear to be small scratches.
Abd: Soft, tender over the lower abdomen, no rigidity or guarding.
Psych: Histrionic otherwise mood/affect rather pleasant.

You had actually just seen this patient 5-6 hours ago when he "fell" on what had appeared to be a diabetic needle which had pierced his penis. The needle is about 1 cm long and he states she felt a gush of fluid go inside. After checking a few blood sugars which were stable and a urine which was completely clean (no blood or infection) you discharged him. He is now back in your department.

He walks around the department in no apparent distress.

What do you do?

Go.

[gigantor]

Heroin addict starting withdrawal.

[DD]

What do you do about it?

[mcclain]

Ask him for a stool sample. He will never poop again.

[pbruss]

i told you not to tell anyone about my visit to the ER. am i missing something? sounds like withdrawl from heroin, which may suck but is not life threatening. is there anything elso on exam?

[kemple]

Definitely breached HIPPA posting about Dr. Bruss like that Dustin, shame. If you REALLY want to be nice 1 dose of benzos but nothing after that and no care package to go home with.

[DD]

Sorry, been busy past week:

Due to the pain I got a CT. I found this:




Anyone know (besides people I told)?

[kemple]

Looks like gas in the bladder? Also a lot of fat stranding posterior, not a colovesicular fistula is it?

[pbruss]

hematoma in corpus cavernous?

[DD]

Diagnosis came back as emphysematous cystitis.

I asked him if he stuck anything up in there, he denied it like 5 times.

If you were like me and had no idea what the hell to do with this, I uptodated it!

Here is the summary:

SUMMARY AND RECOMMENDATIONS

General

●Emphysematous urinary tract infections (UTIs) are infections of the lower or upper urinary tract associated with gas formation. They can manifest as cystitis, pyelitis (gas in the renal pelvis), or pyelonephritis.


●The clinical features of emphysematous pyelonephritis are indistinguishable from those seen in severe acute pyelonephritis. E. coli and K. pneumoniae account for most cases. (See 'Clinical features' above.)


●Abdominal pain is the major clinical manifestation of emphysematous cystitis, while classic symptoms of cystitis (dysuria, urinary frequency, and urinary urgency) occur in about one-half of cases. Pneumaturia may be seen after bladder catheterization. (See 'Clinical presentation' above.)


●The major risk factors for emphysematous UTIs are diabetes and urinary tract obstruction. The infections primarily occur in women at a mean age of about 60 years. (See 'Risk factors for adverse outcomes' above.)


●The diagnosis of emphysematous UTIs is made by abdominal imaging; computed tomography is more sensitive than plain films and can detect obstructing lesions. (See 'Diagnosis' above.)


●Adverse outcomes and mortality are highest when there is extension of gas or abscess to the perinephric or pararenal space (class 3 disease) or involvement of both kidneys or a solitary functioning kidney (class 4 disease). (See 'Prognostic classification' above.)


Treatment

●We recommend parenteral antibiotic therapy for the treatment of all emphysematous urinary tract infections (Grade 1A). In certain cases, other interventions may be warranted, as below. Antibiotic selection is as outlined elsewhere for the management of acute complicated pyelonephritis. (See "Acute complicated cystitis and pyelonephritis", section on 'Pyelonephritis'.)


●For patients with class 1 disease (pyelitis) who do not have abscess formation or obstruction, we suggest treatment with antibiotics alone (Grade 2B). (See 'Suggested approach' above.)


●For other patients with class 1 disease and all patients with class 2 disease (gas limited to the renal parenchyma), we suggest treatment with percutaneous catheter drainage (PCD) and, if present, relief of urinary tract obstruction in addition to antibiotics (Grade 2B). (See 'Suggested approach' above.)


●Management of patients with class 3A or 3B disease (extension of gas or abscess into the perinephric or perirenal space) depends on the presence of the following risk factors: thrombocytopenia, acute renal failure, impaired consciousness, or shock (see 'Suggested approach' above):


•For such patients who have none or only one risk factor, we suggest treatment with PCD and, if present, relief of urinary tract obstruction in addition to antibiotics (Grade 2B). Nephrectomy should be performed if PCD is unsuccessful. However, some urologists feel that early nephrectomy is warranted in all patients with class 3 disease.


•For such patients with two or more of the above risk factors, we suggest immediate nephrectomy in addition to antibiotics (Grade 2B).


●For patients with class 4 disease (bilateral involvement or infection in a solitary functioning kidney) we suggest treatment with bilateral PCD and, if present, relief of urinary tract obstruction (Grade 2B). (See 'Suggested approach' above.)


●For patients with emphysematous cystitis who have intravesicular blood clots or cannot adequately void, bladder irrigation may be needed in addition to parenteral antibiotics. Otherwise, antibiotic therapy alone is usually sufficient. Approximately 10 percent of patients require surgery for debridement, or rarely, partial or total cystectomy. (See 'Emphysematous cystitis' above



In summary: Weird people do weird things and present with weird stuff. The End.

[kemple]

Good case! Thanks for the update.