Teaching Case

A 56-year-old woman was admitted to our hospital due to anorexia, weight loss, and vomiting. The patient had undergone a total gastrectomy for advanced gastric carcinoma 7 months previously. A fluoroscopy study of the upper gastrointestinal was performed to exclude surgical complications.

During the fluoroscopy study, an incidental imaging finding was present. The abdominal radiograph showed a curvilinear area of radiolucency in the expected location of the urinary bladder, representing air (Fig. 1).

Ultrasound demonstrated echogenic air within the bladder wall with dirty shadowing artefact (Fig. 2).

Computed tomography (CT) with oral and endovenous contrast administration, after bladder catheterization, confirmed the presence of intramural gas and diffuse bladder wall thickening, which suggested a diagnosis of emphysematous cystitis (Fig. 3a and 3b).

Emphysematous cystitis represents a rare form of acute inflammation of the bladder, which results in presence of gas within the bladder wall and lumen.

Common clinical symptoms associated are dysuria, increased urinary frequency, and hematuria. Pneumaturia is a rare specific finding. Some risk factors include diabetes mellitus (considered the commonest predisposing factor), neurogenic bladder, immunocompromised state, chronic urinary tract infections, bladder outlet obstruction, Possible non-infectious sources of pelvic air should be considered and include recent bladder instrumentation, enteric fistulas, or trauma.

After the incidental diagnosis of emphysematous cystitis, our patient was questioned about urinary symptoms and complained of urgency and dysuria. The laboratory testing revealed elevated serum white blood count and high C-reactive protein levels. There was no previous history of recent bladder instrumentation or underlying diabetes mellitus. Imagiologic evaluation showed typical findings of emphysematous cystitis, reported next.

Conventional radiography of emphysematous cystitis characteristically shows curvilinear or mottled areas of increased radiolucency in the region of the urinary bladder, separate from more posterior rectal gas.

Ultrasonography commonly shows diffuse bladder wall thickening and increased echogenicity.

CT is a highly sensitive examination that allows early detection of intraluminal or intramural gas. It is also useful in evaluating other causes of intraluminal gas such as enteric fistula, intra-abdominal abscess, adjacent bowel carcinoma, or inflammatory disease.

Additionally, CT can assess the presence of emphysematous pyelonephritis, in which gas involves the renal parenchyma, which is also associated with poorly controlled diabetes mellitus.

Treatment for emphysematous cystitis involves urinary catheterization, antibiotic therapy, and hyperglycemic control.

The patient in this case report started on intravenous tazobactam/piperacillin after blood and urine cultures were obtained, and she was catheterized. Posteriorly, more than 100000 CFU/mL Enterobacter cloacae complex grew in the urine culture, sensitive to ertapenem but resistant to tazobactam/piperacillin. Hemoculture was negative. Ertapenem was started, and the patient’s clinical status improved after 7 days of antibiotic, and the catheter was removed. Ertapenem was stopped on the 14th day of treatment.  A follow-up urine culture was sterile, and the patient was discharged shortly afterwards.