Emphysematous cystitis superimposed to small-bowel obstruction: a case report

Introduction and importance: Emphysematous cystitis (EC) is a rare, potentially life-threatening urinary tract infection characterized by gas formation within the bladder wall and lumen. It predominantly affects elderly diabetic women and is most commonly caused by Escherichia coli . While EC usually responds to conservative management, extravesical complications are exceedingly uncommon. Case presentation: An 85-year-old diabetic woman presented with dysuria, generalized weakness, and cessation of stool and flatus for 1 day. Imaging revealed EC with left-sided pyeloureteritis, pneumoperitoneum, and small-bowel distension consistent with subocclusion. The patient was initially managed conservatively with nasogastric decompression, Foley catheterization, hydration, and antibiotics. Despite partial laboratory improvement, her abdominal symptoms worsened. Exploratory laparotomy revealed a fibrous band and pseudomembranous adhesion between the inflamed bladder wall and the terminal ileum, producing a mechanical transition point. Adhesiolysis was performed, and the bowel was viable. The postoperative course was favorable, and after 15 days of ertapenem therapy, the patient was discharged in good condition. Clinical discussion: This case demonstrates that severe perivesical inflammation, secondary to EC, can extend beyond the bladder, forming adhesions and resulting in mechanical small-bowel obstruction. Such a mechanism is rarely documented. Early recognition and reassessment are essential, as delayed intervention may lead to strangulated or necrotic bowel requiring resection. Conclusion: EC can rarely present as or evolve into a surgical emergency due to inflammatory extension. Close multidisciplinary collaboration between urology, general surgery, and critical care teams is essential for timely diagnosis and management.