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Table of Contents
CASE REPORT
Year : 2019  |  Volume : 9  |  Issue : 2  |  Page : 101-104

Bladder necrosis and perforation in end-stage renal disease and recurrent urinary tract infection: A rare medical emergency


1 Department of Internal Medicine; Departments of Gastroenterology, Morehouse School of Medicine, Grady Memorial Hospital, Atlanta, Georgia, USA
2 Department of Colorectal Surgery, Morehouse School of Medicine, Grady Memorial Hospital, Atlanta, Georgia, USA
3 Department of Gastroenterology; Department of Colorectal Surgery, Morehouse School of Medicine, Grady Memorial Hospital, Atlanta, Georgia, USA

Date of Web Publication26-Jun-2019

Correspondence Address:
Dr. Titilope Olanipekun
Department of Gastroenterology, Morehouse School of Medicine, 720 Westview Dr. S.W, Atlanta, Georgia 30310
USA
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/IJCIIS.IJCIIS_72_18

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   Abstract 


Bladder necrosis and perforation is a rare and life-threatening medical emergency. Risk factors include trauma, malignancy, previous surgery and/or radiation therapy and diabetes mellitus. Signs, symptoms, and imaging findings are often obscure making the diagnosis difficult. Urinary tract infection is common in end-stage renal disease (ESRD) patients who have residual urine production and associated with increased complication and mortality rates. We describe the case of a 57-year-old female with a medical history of recurrent cystitis, type 2 diabetes mellitus and ESRD on hemodialysis that was admitted for septic shock and presumed ischemic colitis. Urine and blood microbiology studies were notable for Escherichia coli. By the second day of hospital admission, her clinical condition significantly deteriorated and was later found to have bladder necrosis and rupture during laparotomy for suspected peritonitis. It is important that clinicians recognize bladder rupture as a potential complication of recurrent bacterial cystitis in ESRD patients on dialysis.

Keywords: Bladder rupture, end-stage renal disease, infection, peritonitis, sepsis


How to cite this article:
Olanipekun T, Effoe V, Turner J, Flood M. Bladder necrosis and perforation in end-stage renal disease and recurrent urinary tract infection: A rare medical emergency. Int J Crit Illn Inj Sci 2019;9:101-4

How to cite this URL:
Olanipekun T, Effoe V, Turner J, Flood M. Bladder necrosis and perforation in end-stage renal disease and recurrent urinary tract infection: A rare medical emergency. Int J Crit Illn Inj Sci [serial online] 2019 [cited 2019 Jul 23];9:101-4. Available from: http://www.ijciis.org/text.asp?2019/9/2/101/261460




   Introduction Top


Bladder necrosis and subsequent rupture is a rare and life-threatening medical emergency.[1],[2],[3] Bladder rupture leads to peritonitis, often diagnosed during surgery and associated with a very high mortality rate.[1] Risk factors include trauma, bladder malignancy, pelvic radiation therapy, previous bladder surgery, and diabetes mellitus.[4] Signs, symptoms, and imaging findings are often obscure and nonspecific making the diagnosis difficult.

Urinary tract infection (UTI) is common in end-stage renal disease (ESRD) patients who have residual urine production.[5] Infections in ESRD patients on dialysis are associated with increased rates of complications and mortality due to immunosuppression.[6] Bladder necrosis and perforation from recurrent UTI in a patient with ESRD has rarely been reported in the literature. This case is structured and reported according to the CARE guidelines and format for reporting of clinical cases.


   Case Report Top


A 57-year-old female with a medical history of hypertension, recurrent cystitis, type 2 diabetes mellitus and ESRD on hemodialysis (3 sessions/week) was brought into the emergency room of an academic hospital. She was apparently in her usual state of health until about 12 h prior to presentation when she was found lethargic and barely conscious. Her medical chart history revealed previous hospital admissions for recurrent UTI and bacteremia. Her last hemodialysis session was 2 days before presentation. Her vital signs were temperature of 95.5F, heart rate 102 beats per minute, respiratory rate 10 cycles per minute, and blood pressure 76/55 mmHg. Other physical examination was remarkable for soft abdomen with mild distension and trace pedal edema. It was difficult to assess for rebound tenderness due to her nearly unconscious state. She was intubated due to concerns for airway protection and admitted to the medical intensive care unit (MICU).

Laboratory findings [Table 1] showed leukocytosis, normocytic anemia, lactic acidosis, and elevated serum creatinine levels. Her hemoglobin A1C level was 6.1%. Arterial blood gas levels were normal. Urinalysis was positive for bacteria, leukocyte esterase, and nitrites. Abdominopelvic computed tomography (CT) scan showed extensive small and large bowel thickening without evidence of obstruction or perforation [Figure 1]; thickening and irregularity of the bladder wall [Figure 2] and mild ascites. Similarly, her abdominopelvic CT scan 1 year prior showed circumferential thickening of the bladder wall consistent with chronic cystitis. Chest X-ray and brain CT scan were normal. She was initiated on intravenous (IV) fluids, empiric wright-based IV antibiotics (Vancomycin and Tazobactam/Piperacillin), norepinephrine for septic shock, and continuous renal replacement therapy for ESRD.
Table1: Patient's blood laboratory parameters at presentation and during hospital admission

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Figure 1: Computed tomography scan of the patient's Abdomen and pelvis. (a) Extensive thickening (red lines) of bowel loops consistent with colitis. (b) Hyperenhancement of the bladder mucosa with thickening and irregularity of the bladder wall (red ring), suggestive of cystitis

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Figure 2: Computed tomography scan of the patient's Abdomen and pelvis showing circumferential thickening of the bladder wall (red line) consistent with cystitis (1 year before presentation)

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The general surgery team was consulted for evaluation possible complicated ischemic colitis based on the abdominal CT findings. The surgical team however made a presumptive diagnosis of ischemic colitis with bacteremia and felt there was no acute surgical intervention warranted in the absence of objectively evident peritonitis. On the second day of admission in the MICU, her clinical condition had severely deteriorated. She was persistently febrile, tachycardic and requiring more doses of norepinephrine to maintain her mean arterial pressure above 65 mmHg. Her abdomen was more distended and laboratory parameters significantly worsened [Table 1]. Blood and urine microbiology studies also resulted for  Escherichia More Details coli. At this point, she was taken to the operating room for urgent exploratory laparotomy for suspected peritonitis from colon ischemia.

Interestingly, laparotomy revealed a necrotic and ruptured bladder wall with free fluid in the abdominopelvic cavity without bowel ischemia or perforation. She subsequently had partial cystectomy. The pathologic analysis confirmed bladder tissue inflammation and necrosis without malignancy. Patient's family decided to withdraw life support treatment and care on postoperative day 4 due to a poor prognosis and she died 11 h later.


   Discussion Top


Atraumatic bladder rupture is rare and a medical emergency. Few cases of tuberculous and candida cystitis leading to bladder rupture have been described,[7],[8],[9] however, to the best of our knowledge, this is the first reported case of bladder rupture from recurrent bacteria cystitis in a patient with ESRD. Although UTIs are commonly encountered in hospitalized chronic dialysis patients, Candida is the most frequently observed pathogen.[10] Chronic and recurrent cystitis lead to inflammatory changes in the bladder with progressive weakening of the bladder wall and subsequent perforation. Our patient also had diabetes (optimally controlled) and ESRD (receiving hemodialysis), two conditions that predispose to recurrent UTIs.[11] No other risk factors for bladder perforation were identified in this case. Although the management of dialysis patients with UTI is similar to those without renal failure, antimicrobials should be tailored to cultured organisms and renally dosed.

Spontaneous bladder rupture with peritonitis typically presents with fever, abdominal pain, nausea, vomiting, and inability to pass stool or gas.[1],[2] Furthermore, abdominal and pelvic CT scan studies usually demonstrate free fluid in the peritoneal cavity, with nonspecific bladder findings ranging from distension and thickness to irregularities and defects in the bladder wall.[1],[12] The diagnostic imaging of choice is CT cystography which has now replaced the conventional cystography due to the usual complexity of the injury and wide spectrum of findings.[13],[14] Timely and appropriate diagnosis of bladder rupture often requires a high index of suspicion.

This case was more clinically challenging because our patient did not report any of the usual peritonitis symptoms. She was severely lethargic and had septic shock at presentation. Similar cases in the literature have also highlighted the atypical presentation, and diagnostic dilemma often encountered in spontaneous or atraumatic urinary bladder rupture.[15] Kivlin et al.[12] described two patients with nonspecific abdominal symptoms on presentation with progression to altered mental status and were eventually diagnosed with urinary bladder rupture through CT cystography, In addition, Limon et al.[16] described a case of a middle-aged woman with diabetes mellitus who presented with abdominal pain without urinary symptoms and was later found to have bladder rupture during laparotomy. The misdiagnosis rate of urinary bladder rupture is more than 50% and mortality from late diagnosis and intervention is close to 50%.[16],[17]

Our patient's abdominal and pelvic imaging findings at presentation were more consistent with ischemic or infectious colitis, without indication of peritonitis which made a preoperative diagnosis difficult. Retrospectively, her history of recurrent cystitis with chronic bladder inflammatory changes noted on her pelvic CT scan and evidence of sepsis at presentation should have prompted further evaluation with CT cystography for possible bladder necrosis and perforation.


   Conclusion Top


The prognosis of bladder rupture is very poor, and early diagnosis may improve mortality outcomes. The diagnosis could be very difficult even with appropriate imaging study and more challenging with an atypical presentation as in this case. Although our patient's history of diabetes mellitus and ESRD at baseline likely contributed to her poor postoperative course; early intervention is still desired. It is important that healthcare providers, particularly acute care and emergency physicians have a high index of suspicion and recognize spontaneous bladder rupture as a potential complication of recurrent bacterial cystitis in ESRD patients on dialysis. Patients with ESRD who develop bacterial cystitis should be adequately treated to prevent recurrence and possible urinary bladder rupture.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. The patient's family signed the consent form for her clinical information and images to be reported and potentially published. The patient's family understand that patient's names and initials will not be published, and due efforts will be made to conceal her identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
   References Top

1.
Sawalmeh H, Al-Ozaibi L, Hussein A, Al-Badri F. Spontaneous rupture of the urinary bladder (SRUB); A case report and review of literature. Int J Surg Case Rep 2015;16:116-8.  Back to cited text no. 1
    
2.
Muneer M, Abdelrahman H, El-Menyar A, Zarour A, Awad A, Al-Thani H, et al. Spontaneous atraumatic urinary bladder rupture secondary to alcohol intoxication: A Case report and review of literature. Am J Case Rep 2015;16:778-81.  Back to cited text no. 2
    
3.
Hariharasudhan S, Krishnamoorthy S, Shroff S. Spontaneous rupture of urinary bladder (SRUB) in a young male, presenting as anuria – A case report and review of literature. Open Urol Nephrol J 2014;7:64-6.  Back to cited text no. 3
    
4.
Mitchell T, Al-Hayek S, Patel B, Court F, Gilbert H. Acute abdomen caused by bladder rupture attributable to neurogenic bladder dysfunction following a stroke: A case report. J Med Case Rep 2011;5:254.  Back to cited text no. 4
    
5.
Manhal F, Mohammed AA, Ali KH. Urinary tract infection in hemodialysis patients with renal failure. Fac Med Baghdad 2012;54:38-41.  Back to cited text no. 5
    
6.
Sarnak MJ, Jaber BL. Mortality caused by sepsis in patients with end-stage renal disease compared with the general population. Kidney Int 2000;58:1758-64.  Back to cited text no. 6
    
7.
Kabarriti AE, Ramchandani P, Guzzo TJ. Spontaneous urinary bladder perforation: An unusual presentation of diabetes mellitus. Urol Case Rep 2014;2:109-11.  Back to cited text no. 7
    
8.
Kong CH, Ali SA, Singam P, Hong GE, Cheok LB, Zainuddin ZM, et al. Spontaneous bladder perforation: A rare complication of tuberculosis. Int J Infect Dis 2010;14 Suppl 3:e250-2.  Back to cited text no. 8
    
9.
Pal RP, Terry TR, Khan MA. Spontaneous intra-peritoneal perforation of the bladder secondary to peritoneal tuberculosis. J Clin Urol 2009;2:213-4.  Back to cited text no. 9
    
10.
D'Agata EM, Mount DB, Thayer V, Schaffner W. Hospital-acquired infections among chronic hemodialysis patients. Am J Kidney Dis 2000;35:1083-8.  Back to cited text no. 10
    
11.
Nicolle LE. Urinary tract infections in special populations: Diabetes, renal transplant, HIV infection, and spinal cord injury. Infect Dis Clin North Am 2014;28:91-104.  Back to cited text no. 11
    
12.
Kivlin D, Ross C, Lester K, Metro M, Ginsberg P. A case series of spontaneous rupture of the urinary bladder. Curr Urol 2015;8:53-6.  Back to cited text no. 12
    
13.
Lis LE, Cohen AJ. CT cystography in the evaluation of bladder trauma. J Comput Assist Tomogr 1990;14:386-9.  Back to cited text no. 13
    
14.
Gross JS, Rotenberg S, Horrow MM. Resident and fellow education feature. Bladder injury: Types, mechanisms, and diagnostic imaging. Radiographics 2014;34:802-3.  Back to cited text no. 14
    
15.
Dubey IB, Mohanty D, Jain BK. Diverse presentation of spontaneous rupture of urinary bladder: Review of two cases and literature. Am J Emerg Med 2012;30:832.e1-3.  Back to cited text no. 15
    
16.
Limon O, Unluer EE, Unay FC, Oyar O, Sener A. An unusual cause of death: Spontaneous urinary bladder perforation. Am J Emerg Med 2012;30:2081.e3-5.  Back to cited text no. 16
    
17.
Ryohei M, Kamiizumi Y, Tani Y, Ishizuka C, Kashiwakura S, Tsuji T, et al. Spontaneous Rupture of the Urinary Bladder Due to Bacterial Cystitis. Journal of Surgical Case Reports 2018. doi:10.1093/jscr/rjy253.  Back to cited text no. 17
    


    Figures

  [Figure 1], [Figure 2]
 
 
    Tables

  [Table 1]



 

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