Teaching Case

History of alcoholic cirrhosis, referred for gastrointestinal bleeding caused by ruptured esophageal varices, which were successfully treated with blood transfusion and endoscopic sclerotherapy. Ten days after admission, the patient complained of abdominal discomfort and colicky pain. Physical examination revealed mild abdominal distension and diffuse tenderness. Temperature was 36.8° C. Laboratory tests revealed a white blood cell count of 14.600/mm3.

The patient, with a history of alcoholic cirrhosis, was referred to the hospital for gastrointestinal bleeding caused by ruptured esophageal varices, which were successfully treated with blood transfusion and endoscopic sclerotherapy. Ten days after admission, the patient complained of abdominal discomfort and colicky pain. Physical examination revealed mild abdominal distension and diffuse tenderness. Temperature was 36.8° C. Laboratory tests revealed only a white blood cell count of 14.600/mm3. Plain film of the abdomen was performed, followed by CT scan of the pelvis.

Emphysematous cystitis is a rare clinical entity, in which bacteria produce gas in the bladder wall and lumen. It is associated with diabetes mellitus, urinary retention like neurogenic bladder dysfunction or outlet obstruction. Patients are usually elderly and debilitated. Emphysematous cystitis is not associated with specific symptoms. Patients may complain of irritative symptoms of cystitis, abdominal discomfort or pneumaturia. They may be asymptomatic or have symptoms of coexisting disease, like alcoholic liver disease or hemorrhagic cystitis. The most common organisms isolated from urine culture are E. Coli and Enterobacter aerogenes. Bacterial fermentation of glucose gives carbon dioxide gas, which collects in (the lumen of) the submucosa of the bladder. Glucosuria is not essential for gas production and it is possible that albumin may be fermented as well. Clinical and physical findings are not specific, and the diagnosis is usually first suspected by radiologic examinations. Plain film of the abdomen may reveal a radiolucent line or streaks of gas bubbles may outline the bladder wall. CT is the most sensitive means to confirm the diagnosis. Treatment should establish adequate bladder drainage and broad spectrum antibiotics should be administered. The key to successful management is early diagnosis and treatment.