Asif Zia, MD, MPH

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• Asif Zia, MD, MPH

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History

• 83 year old presented via EMS to the ED.
• Resident of an assisted living facility.
• Complained of abdominal and suprapubic pain.
• Has had an in-dwelling Foley catheter for several
  months.
• Denied fever or chills.
• Was a poor historian, so history was difficult to
  obtain.

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History 2

• PMHx CAD with severe left Main disease, HTN, OA,
  Glaucoma, BPH, DM.
• MEDS Cardizem, Glyburide, Vioxx, Lisinopril,
  Prilosec.
• ALL NKDA
• SHX No history of smoking or ETOH use. Lives at
  an assisted facility.

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Physical Exam

• Elderly male in NAD
• Vitals T-97.8, P-84, BP-163/95
• LUNGS CTA bilaterally
• CVS heart sounds S1 and S2 with a III/VI
  holosystolic murmur at the apex.
• ABD Diffuse suprapubic tenderness. No rebound.
  BS positive. Foley in place.
• EXT NO clubbing, cyanosis or edema.

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Labs

• WBC 10, HG 13, Plats 273
• BUN-CR-1.3, bicarb24, lipase-4, amylase-94,
  LFTs-WNL. Urinalysis

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CT Scan 1
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CT Scan 2
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CT Scan 3
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CT Scan Report
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Images From NEJM (Jul17, 349 (3) 258
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Questions?

• What is emphysematous cystitis?
• What are the causative organisms?
• How is it treated?

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Emphysematous Cystitis

• This is a rare disorder (lt200 cases reported in
  worldwide literature).
• 1st reported in 1882 by Keyes.
• It is a complication of a UTI in which bacteria
  produce gas in the bladder wall and lumen.
• DM, Various neurogenic bladder diseases and
  chronic UTI are predisposing conditions (anything
  that causes urine stasis).

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Emphysematous Cystitis 2

• Seen more commonly in elderly, debilitated and
  immunocompromised patients.
• Women are more commonly affected (21) than men.
• Severity varies from life threatening to
  asymptomatic.

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Microbiology

• E. Coli is the commonest pathogen.
• Other organisms include
• Aerobacter aerogenes
• Various streptococci
• Proteus
• Nocardia
• Candida albicans
• Clostridium perferingens has also been reported
  and may not grow in routine culture.
• The gas is carbon dioxide, which is produced by
  bacterial fermentation of urinary glucose or
  albumin within the bladder wall.

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Diagnosis

• Diagnosis often made incidentally on a plain film
  of the abdomen.
• Bladder may contain intramural air or air-fluid
  levels.
• CT scan can show gas in the bladder wall as well.
• Cystoscopy is useful in differentiating from gas
  from an enterovesical fistula.
• History of pneumaturia is rare.

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Differential Diagnosis

• Enterovesical fistula usually secondary to
• Diverticulitis
• Crohns disease
• Rectosigmoid carcinoma
• Trauma
• Urinary tract instrumentation

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Treatment

• Early broad spectrum antibiotics (include both
  aerobic and anaerobic coverage).
• Drainage of the bladder (usually a urethral
  catheter is sufficient).
• Management of hyperglycemia.
• Organisms that are often overlooked as
  saprophytic (e.g. C. albicans) should be given
  consideration as many patients are
  immunocompromised.

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Our patient

• Initially started on Piperacillin-tazobactam and
  Cipro.
• Had his Foley catheter changed.
• Cultures grew

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Our Patient contd.

• Antibiotics eventually changed to cipro after 3
  days.
• Responded very well to antibiotics with
  resolution of his abdominal pain.
• Discharged home to complete a total of 14 days of
  antibiotics.

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Conclusion

• Rare condition associated with air in the urinary
  tract.
• Differentiate from air in the bladder due to
  fistulation.
• Commonly due to bacteria such as E.Coli.
• Rarely can be caused by C.Perferingens and
  C.Albicans.
• Treat by appropriate antibiotics, urinary
  drainage and control of hyperglycemia.