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Objective:To analyze the clinical characteristics of invasive intervention-related intestinal fistula in patients with acute pancreatitis (AP).Methods:We retrospectively analyzed the clinical data of 177 moderately severe acute pancreatitis (MSAP) or severe acute pancreatitis (SAP) patients who received invasive intervention in Peking Union Medical College Hospital from January 2003 to December 2022. Patients were divided into fistula group and non-fistula group based on the presence or absence of fistula after or during receiving invasive interventions. The age, gender, etiology, systemic inflammatory response syndrome(SIRS), impairment of organ function, revised Atlanta classification, bedside index of severity of acute pancreatitis(BISAP), Balthazar CT classification, extra-pancreatic involvement and secondary infection of local complications, indications, timing and modalities of invasive interventions, length of hospitalization, length of intensive care and outcomes were recorded. The differences on clinical characteristics were compared between the two groups.Results:Intestinal fistulae were found in 21(11.9%) cases during or after invasive intervention, including 8 during or after percutaneous drainage and 13 during or after surgeries. 51 cases received endoscopic drainage or debridement and no intestinal fistula occurred after endoscopic management. Compared to patients without fistula, the median age was younger in the fistula group (36 vs 45 years, P=0.014), and the occurrence of SIRS (95.2% vs 59.6%, P=0.001), extra-pancreatic invasion (100.0% vs 67.3%, P=0.002), and secondary infection (71.4% vs 36.5%, P=0.002) were higher. Patients with fistula had a longer median length of hospitalization (71 vs 40 days, P=0.016) and intensive care (8 vs 0 days, P=0.002). All patients in the fistula group had peri-pancreatic, abdominal and retroperitoneal involvement seen on imaging or intraoperatively. The intestinal fistulae mainly occurred in the colon ( n=13, 61.9%) and the duodenum ( n=6, 28.6%). The confirmed diagnosis of fistulae was based on transfistula imaging ( n=11) or digestive tract imaging ( n=5). Among 13 cases with colonic fistulae, nonsurgical treatment was preferred in 9 cases, and surgeries of fistula repairmen or proximal ostomy were preferred in 4 cases. Among 8 cases with non-colonic fistulae, nonsurgical treatment was preferred in 7 cases, and only 1 case repaired the fistula immediately during the intraoperative detection. Conclusions:Intestinal fistula is an important complication of severe AP, and it is closely associated with invasive interventions. Improved invasive intervention strategies may help prevent intestinal fistula formation; timely and effective management of intestinal fistula may help avoid complications and shorten hospitalization.
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Background: Emphysematous pyelonephritis should be suspected in every diabetic patient, presenting with features of acute pyelonephritis. E.coli is the most common organism associated with EPN. Aim: To study the clinical features, radiological classification and risk factors assess the prognostic factors and to study different management modalities of Emphysematous pyelonephritis and their outcomes. Materials and methods: It was prospective study done on 48 patients who were diagnosed to have Emphysematous pyelonephritis from various departments in Osmania General Hospital from October 2004 to October 2006 were included in the study. The diagnosis of EPN was confirmed by plain CT KUB scan. Results: All the 48 patients with EPN had diabetes mellitus (DM). All the 48 patients had poorly controlled DM. Left kidney was involved in 54.1% and Right kidney in 37.5% of cases. 6.25% of cases had bilateral involvement. Fever (93%) and tachycardia (64.5%) were most common presentation in patients. Thrombocytopenia was seen in 50% of these patients and 12% of patients with thrombocytopenia required platelet transfusion. Shock during initial presentation was seen in 22.9% of patients. 16.6% of patients presented with altered sensorium. E.coli was grown in 78% of patients and klebsiella in 6% of patients. There were 6 patients with dry EPN and 42 patients with wet EPN. 41.6% of patients had Class 2 EPN (Commonest class in our study), 25% of patients had class 3A EPN, 22.9% had Class 1 EPN, 6.25 had Class 4 EPN. 15.63% of patients were treated conservatively with antibiotics according to culture and sensitivity. 78% of patients required minimally invasive intervention. Nephrectomy was done in 6% of patients. Mortality rate in our study was 8.3%. V. Vishnu Vardhana Reddy, K. Panduranga Rao. A clinical study of emphysematous pyelonephritis. IAIM, 2018; 5(2): 150- 159. Page 151 Conclusions: Nephrectomy should be promptly attempted for patients not responding to conservative methods and patients with extensive, fulminant course of disease. Pre-existing CKD status, shock at presentation and altered sensorium are the poor prognostic factors in this study.