A rare occurrence of hepatic portal venous gas in emphysematous pyelonephritis
A 65-year-old hypertensive diabetic female patient developed colicky left flank pain radiating to the groin. Ultrasonography revealed an 8.0 mm mid-ureteric calculus for which she underwent ureterorenoscopic lithotripsy and double-J stenting. The stent was removed after 6 weeks. A week after stent removal, she developed continuous left flank pain, progressive abdominal distension, obstipation, and high-grade continuous fever. A large ovoid left lumbar mass was palpable. She had anemia (hemoglobin 8 g/dL), polymorphonuclear leukocytosis (total leucocyte count 42,600/mm3) and raised blood glucose (400 mg/dL), blood urea (55 mg/dL) and serum creatinine (2.7 mg/dL) levels. Non-contrast computerized tomography (CT) revealed a grossly enlarged left kidney (15.5 cm × 12.0 cm × 19.0 cm) distended with fluid and air. Air was also noted in the peritoneal cavity, retroperitoneum, right inguinal canal and hepatic portal venous radicals [Figures and ]. Retroperitoneal and mesenteric lymphadenopathy was present. A diagnosis of emphysematous pyelonephritis, Wan type 2, was made. Emergency percutaneous nephrostomy drained 1150 ml of pus, which grew Escherichia coli on culture. The patient was managed successfully with central venous pressure-guided intravenous fluids, insulin and broad-spectrum antibiotics. Renal scintigraphy revealed non-functioning left kidney. The patient underwent left subcapsular nephrectomy with uneventful recovery. Histopathology of the resected kidney suggested “end-stage kidney” with chronic pyelonephritis.