A RARE CASE OF PERINEPHRIC ABSCESS SQUELED INTO ACUTE INTESTINAL OBSTRUCTION

1. General Surgery, Senior Resident, Aiims Raipur, Chhattisgarh, India. 2. Surgical Oncology, Senior Resident, Aiims Bhopal, Madhya Pradesh, India. ...................................................................................................................... Manuscript Info Abstract ......................... ........................................................................ Manuscript History Received: 30 June 2020 Final Accepted: 31 July 2020 Published: August 2020


Introduction:
A perinephric abscess is a collection of suppurative material in the perinephric space. Perinephric abscess results from perirenal fat necrosis. A perinephric abscess is a life-threatening entity that is usually a complication of urologic infection. Most perirenal abscesses were due to prolonged bacteremia with Staphylococcus aureus followed by hematogenous seeding before the era of antibiotics. More than 75% of perinephric abscesses are now due to complications of urinary tract infection (UTI). Case report:A 50 years old male came in our emergency department with complaint of on and off pain in left flank of abdomen for 1month, Burning micturation for 15 days, intermittent fever for 7 days. Initially empirical medical treatment with DJS done but symptom not relived and feature of onstruction developed. Then on exploratory Laprotomy omentum was attached to wall of retroperitonial perinephric abscess which was about to burst. This omental adhesion was causing acute intestinal obstruction due to small bowel compression. Then adhesiolysis & repositioning of the omentum done and I&D done via retroperitonial approach. Patient got relieved after surgery and passed motion on 2 nd post op day and dischared on 5th day. Conclusion:Even uncomplicated urinary tract infection can land up into life-threatening complication such as perinephric abscess, acute obstruction so we kept in mind about this complication.

Introduction:-
A perinephric abscess is a collection of suppurative material in the perinephric space [1]. Perinephric abscess results from perirenal fat necrosis [2] . A perinephric abscess is a life-threatening entity that is usually a complication of urologic infection. Most perirenal abscesses were due to prolonged bacteremia with Staphylococcus aureus followed by hematogenous seeding before the era of antibiotics [3] . More than 75% of perinephric abscesses are now due to complications of urinary tract infection (UTI). A perinephric abscess is more diffuse and affects the renal capsule and Gerota's fascia. These abscesses can extend from the Gerota's fascia into the psoas and transversalis muscles as well as the peritoneal cavity and the pelvis. Perinephric abscesses carry a mortality rate of up to 56%. This rate partly is due to long delays in diagnosis and the comorbid conditions. Even with modern surgical therapy, the mortality rate is 8-22% and significant morbidity occurs in 35% of patients.

Case Presentation:
A 50 years old male came in our emergency department with complaint of on and off pain in left flank of abdomen for 1month, Burning micturation for 15 days, intermittent fever for 7 days. On examination patientwas conscious, well oriented,average built, P-68/minute regular, BP-138/86mm Hg, normal temperature. Per abdomen examinationit was soft nontender,Bowel sound present, normal genitalia, Passed flatus and motion. Investigation-Total leucocyte count[TLC]was 11800/mm3, Platelets was 3 lac, In Urine microscopy-8-10 pus cells/hpf. USG whole abdomen suggestive of mild Left hydronephosis. Provisional diagnosis-Urinary tract infection with Left hydronephrosis. Now we start empirical antibiotic and syrup alkacitrol. After two dayspatient had no improvement instead he complaint pain in left side abdomen and continuous fever for 2 days. On examination-General condition was poor, febrile, pulse-114/minute, BP-108/70mmHg, Per abdomen examination-fullnessin left hypochondrium& left lumber region and tenderness in these area. Per rectal with in normal limit. On blood investigation TLC-18,000/mm3, creatinine-3.2mg/dl(previous was1.

Discussion:-
Perinephric abscess is an uncommon complication of urinary tract infections. The incidence ranges from 1-10 cases for every 10,000 hospital admissions. Men and women are affected with equal frequency. Patients with diabetes account for one third of all perinephric abscess cases. [4] Escherichia coli, Proteus species, and Staphylococcus aureus are the usual etiologic organisms. Predisposing factors for perinephric abscess include neurogenic bladder, vesicoureteral reflux, bladder outlet obstruction, renal papillary necrosis, obstructing calculus, genitourinary tuberculosis, trauma (eg, renal biopsy, [5] urinary instrumentation, urologic surgery), immunosuppression, and intravenous drug abuse. Because of nonspecific findings, in many cases, diagnosing a 1297 perinephric abscess can be difficult. Typically, patients present with a history of urinary tract infections. An infection may be followed in 1-2 weeks by fever and unilateral flank pain. However, this is an uncommon presentation. Typically, the onset of symptoms is insidious, and 58% of patients have symptoms for more than 14 days. The most common symptoms include fever (66-90%), flank or abdominal pain (40-50%), chills (40%), dysuria (40%), weight loss, lethargy, and gastrointestinal symptoms (25%). Pleuritic pain may occur due to diaphragmatic irritation. [6] Various complications can occur, including the following: Bleeding,Flank abscess, Fistula formation to stomach, small bowel, duodenum, lung, Subphrenic abscess, Empyema, Pneumonia, Atelectasis, Sepsis, Possible rupture into peritoneum, Possible perforation through diaphragm. The mainstay of treatment for perinephric abscess is drainage. (incised and drained through a retroperitoneal approach) Antibiotics are mainly used as an adjunct to percutaneous drainage because they help to control sepsis and to prevent the spread of infection. [7] Surgical intervention may be indicated in cases when a perinephric abscess is not successfully treated with antibiotic therapy and percutaneous catheter drainage.Empiric therapy can be delayed for percutaneous drainage in a stable patient if drainage can be done immediately to identify the causative organism. Surgical drainage of the abscess and/or nephrectomy is warranted in a patient that failed medical treatment. Nephrectomy is also warranted in patients with a chronically infected and atrophic kidney that develop a perinephric abscess.

Conclusion:-
Even uncomplicated urinary tract infection can land up into life-threatening complication such as perinephric abscess, acute obstruction so we kept in mind about this complication. Early diagnosis, immediate drainage, antibiotic therapy with surgical management can reduce the mortality.