Emphysematous pyelonephritis from colorenal fistula

Case contributed by Dr Derek Smith

Presentation

Abdominal pain and sepsis, CRP >500. Acute renal failure. Previously known diverticular disease. For unenhanced CT.

Patient Data

Age: 75 years
Gender: Female

Normal size of both kidneys. No free fluid. Hypoechoic left upper pole.

Unenhanced CT performed due to renal failure.

Multiple foci of gas within left kidney, with necrotic anterior cortex/medulla, with gas extending into hilm and proximal ureter.

Surrounding mesenteric stranding and fluid in left paracolic gutter.

Left colon diverticulosis, some more acute inflammation adjacent to the kidney.

No obstruction of the left ureter. Unremarkable right kidney and collecting system. Catheterized urinary bladder.

Percutaneous drainage of infected left renal system.

Initial puncture instilled contrast into collection, but drainage via left renal vein and IVC noted.

Wire re-positioned, with further instillation of contrast.

Pigtail catheter introduced, with contrast now filling the adjacent descending colon.

Case Discussion

Emphysematous pyelonephritis is a relatively rare but severe infection of the renal system. In this case a diverticular colorenal fistula was suspected, confirmed on dynamic IR procedure, and eventually on pathology as the patient underwent a Hartmann procedure with nephrectomy.

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