A case of emphysematous cystitis diagnosed by exploratory laparotomy
An 83 year old female, who had been hospitalized for years due to schizophrenia, complained of vomiting and diarrhea for 2 days. She had no history of diabetes mellitus, neurogenic bladder, or previous antimicrobiotic therapy, but had a urinary catheter in place for a considerable period since she was bedridden for many years. The diagnosis was acute enterocolitis and intravenous fluid was administered. After she developed a chill and lower abdominal pain with muscular defense, she was diagnosed as surgical acute abdomen and transferred to our emergency department.\nOn arrival, her body temperature was 38.2°C, blood pressure was 150/70 mmHg with a regular heart rhythm of 110 beats/min, and her respiratory rate was 22 breaths/min. Physical examination revealed tenderness over the lower abdomen with muscular defense, rebound tenderness, and loss of bowel sounds. Laboratory examination revealed a normal white blood cell count with elevated C-reactive protein (24.9 mg/dL). Urinalysis was unremarkable. An X-ray of the abdomen showed gas collection in the pelvic cavity, and CT scans of the abdomen revealed intraperitoneal fluid collection and abnormal gas accumulation in the pelvic space. The distribution of this abnormal gas was between the abdominal wall and retroperitoneal cavity including the urinary bladder wall, and its association with the intraperitoneal cavity was unclear ().\nIn accordance with the history, physical examinations, and radiological findings, the patient was diagnosed as acute peritonitis with possible perforation or penetration of the lower intestine, and exploratory laparotomy was performed. At laparotomy, severe inflammatory changes were observed in the peritoneum from just below the umbilicus to the lower abdomen (). Ascites in the peritoneal cavity was slightly turbid, but without a stool smell and there was almost no intraperitoneal inflammation. Other abdominal structures were intact, however, the bladder was swollen. When the bladder wall was pushed from the peritoneal cavity side, an unusual crackling sensation was felt and purulent urine was excreted via the urethral catheter. Dull dissection of the retroperitoneal cavity toward the bladder wall showed markedly loose connective tissue around the bladder due to severe emphysematous change, and the boundary with the bladder wall was unclear. These findings indicated emphysematous cystitis. The patient was placed on 1.5 g/day of intravenous doripenem for broad antibiotic coverage. Afterwards, K. pneumoniae was isolated from cultures of peritoneal fluid, urine, and blood (). Antimicrobiotic therapy was changed to intravenous administration of ceftriaxone at 2.0 g/day for 2 weeks. The patient recovered uneventfully and follow-up CT imaging after 3 weeks demonstrated resolution of the bladder wall emphysema.