http://renalfellow.blogspot.tw/2016/05/emphysematous-pyelonephritis.html?utm_source=feedburner&utm_medium=email&utm_campaign=Feed:+blogspot/yKDtf+(Renal+Fellow+Network)
這是來自英國愛丁堡皇家醫院一位醫師的筆記，看了文章後讓人覺得醫療真是有很高的不可預測性。
這是一位74歲男性，因為acute on chronic kidney injury住院，病人症狀：
2 days of generalised lower abdominal pain and vomiting but NO urinary symptoms or fever.
過去病史：
advanced CKD, benign prostatic hypertrophy and a slow growing renal cell tumour under radiological surveillance.
檢查：
His vital signs were normal and he had mildly raised inflammatory markers.
因為假日時醫院沒有超音波檢查，所以作者排了CT KUB來排除obstruction。結果報告讓他，也讓我十分驚訝，emphysematous pyelitis。
作者補充說明，當病人進到醫院時，有單導測量餘尿量，導尿時，有一陣空氣刷出，當時作者也沒聯想到膀胱內有空氣。
更糟的是，一開始這病人U/A報告是‘no significant bacteriuria’，but subsequently grew a resistant E. Coli >1,000 - <10 cfu="" culture="" ml="" p="">
泌尿科醫師看了CT，覺得parenchyma was not involved and he had no abscess formation，所以內科治療即可。
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若是這個病人，沒有在假日時做這CT檢查，甚而發現問題治療，等到下週一上班時，不知道會不會像炸彈一樣爆了？一個假日acute on CKD患者，在台灣的我們能排CT嗎？若能做個renal echo就很棒了吧？
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接下來是讀書時間
Emphysematous UTIs are gas forming infections of the urinary tract and can manifest as
三種程度
1) cystitis (gas within the bladder wall), (此病例)
2) pyelitis (gas within the collecting system) or
3) pyelonephritis (gas within renal parenchyma or perinephric tissues).
危險因子：
Diabetes and urinary tract obstruction are major risk factors, present in around 80% and 20% of patients respectively.
致病菌：
most commonly E. Coli and Klebsiella pneumoniae, with Candida being involved less frequently.
診斷：
CT which shows the extent of gas within the urinary tract and any obstruction.
治療看影響範圍，最嚴重甚至要腎切除：
Treatment depends on the extent of infection. It ranges from parenteral antibiotics alone for patients where gas is limited to the collecting system with no obstruction, to percutaneous drainage of purulent material and antibiotics if there is abscess formation or extension of gas into the perinephric space, to nephrectomy in patients with diffuse gas and extensive renal destruction.
作者從此病例學習到，也讓我們學習：
1) ‘no significant bacteriuria’ 和‘no growth’是不同的
2) Ultrasound還是第一線檢查，雖然emphysematous UTI還是要CT才能看清楚。
3) Pneumaturia (氣尿)，這個症狀若出現，要追查是否有以下可能原因：emphysematous UTI，vesicovaginal or vesicoenteric fistulae, renal tumour infarction and recent instrumentation。尤其是在導尿時，若有空氣放出，特別要去想原因。
Post by Ailish Nimmo, Royal Infirmary of Edinburgh
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