CASE
A 65-year-old man presented to the emergency department with 1 day of painless hematuria. He reported that 2 days earlier, he had experienced dysuria with nausea and two episodes of vomiting but without abdominal pain. He denied any illness or trauma before the onset of symptoms. His medical history was significant for hypertension, type 2 diabetes mellitus (A1C was 7.4% at arrival), and chronic obstructive pulmonary disease (with a 50 pack year history of smoking). He also had a history of gout, hyperlipidemia, and anxiety/depression. The patient denied any alcohol or illicit drug use. He was admitted to the veteran's hospital in Salem, Virginia, with a provisional diagnosis of emphysematous cystitis. His medications on admission included allopurinol, aspirin, diltiazem, gabapentin, glucagon, glucose, insulin, lisinopril, metformin, simvastatin, and venlafaxine.
On physical examination, the patient's temperature was 97.2°F; pulse, 105 beats per minute; and BP, 115/63 mm Hg. Cardiac and pulmonary findings were unremarkable. The abdomen was soft and nontender with positive bowel sounds. The extremities showed no signs of clubbing, cyanosis, edema, or pain. Laboratory evaluation revealed an elevated WBC count of 13,500 cells/mm3 and a glucose level of 277 mg/dL. Other laboratory values were within normal limits. Initial urinalysis revealed red, turbid urine with a pH of 6. Microscopic urinalysis revealed hematuria with greater than 50 RBCs and greater than 50 WBCs per high-power field.
CT was ordered. The patient was given 100 mg of iporomide IV contrast medium and placed in a thin-slice CT scanner in order to completely evaluate the extent of gas infiltration in the urinary bladder and wall. Figure 1 displays the results of abdominal CT with and without contrast.
What do these images reveal?
