Enterovesical fistulas in Crohn''s disease.

A total of 19 enterovesical fistulas were recorded in a series of 799 patients with Crohn's disease (2.4%). The origin of the fistulas was: ileum (9), colon (6) and four were complex involving the small and large bowel. Only 13 patients presented with urinary symptoms: pneumaturia (9), haematuria (1) and urinary tract infection (3). Four fistulas were identified incidentally during contrast radiology, one fistula was identified during a laparotomy and one further fistula developed after a previous resection for Crohn's disease. Four patients were managed conservatively and all are asymptomatic, but it is not known whether the fistula has healed. Twelve fistulas were resected: 9 healed, 2 recurred and 1 patient died following resection for a malignant fistula complicating Crohn's disease. Early in the series three patients were managed by bypass or defunction of the fistula. In all cases the sepsis persisted resulting in mortality. Persistent symptomatic fistulas should be treated by resection of the affected segment of bowel with primary anastomosis if appropriate. The defect in the bladder should be closed over an indwelling catheter which should not be removed until there is radiological confirmation that the bladder defect has healed satisfactorily.     

Enterovesical fistula complicating Crohn's disease: report of two cases]

Two female patients with enterovesical fistula complicating Crohn's disease are presented. Case 1: A 40-year-old woman having a 10-year history of diarrhea presented with vesical irritability of a three months duration. Administration of antibiotics did not relieve her of the symptoms and then pneumaturia appeared. Cystoscopic examination revealed fistulous opening. Barium enema study depicted rectovesical fistula. After partial cystectomy and temporary colostomy, ileocecal lesion was shown by contrast study and resection of ileocecal segment was performed seven months later. Case 2: A 33-year-old woman presented with vesical irritability of 7 years duration and pneumaturia and fecaluria of 4 years duration. Cystoscopic examination revealed localized bullous edema but no apparent fistula. Cystography, as well as contrast studies demonstrated ileo-vesical, ileo-ascending colonic and ileo-sigmoidal fistulas. One-stage resection of diseased intestine and partial cystectomy were performed. In both cases, pathological diagnoses of Crohn's disease was made, and postoperative course was uneventful for over 10 months. Thirty eight cases of enterovesical fistula complicating Crohn's disease are reviewed.     

Management of the bladder during surgical treatment of enterovesical fistulas from benign bowel disease

BACKGROUND: Management of the bladder in enterovesical fistulas from benign bowel disease is not well described in the literature and there is no clear consensus. STUDY DESIGN: A retrospective chart review was done of all patients with benign bowel disease and an enterovesical fistula who underwent definitive surgical management between January 1993 and December 2005. Patients were excluded if they had any history of abdominal cancer or pelvic radiation. Surgical management protocol for enterovesical fistulas included a period of perioperative bowel rest, surgical exploration, separation of the fistulized bowel from the bladder, resection of the diseased bowel segment, and Foley catheter placement for 1 week. RESULTS: Seventy-four patients were eligible for the study. The average patient age was 54.3 years (range 19 to 88 years old). Twenty-six women and 48 men underwent celiotomy and segmental resection of the offending bowel and bowel side of the fistula. The bladder side of the fistula was managed by Foley catheter alone in 68% and by surgical repair in 32%. Fifty-two patients had diverticulitis (70.3%) and 22 had Crohn's disease (29.7%). Mean followup was 26.4 months, and median followup was 6.45 months. One patient developed a colocutaneous and vesicocutaneous fistula after celiotomy. The remaining bladder defects healed within 1 week. CONCLUSIONS: Successful surgical management of most enterovesical fistulas from diverticulitis or Crohn's disease requires only resection of the diseased bowel, with minimal need for repair or resection of the bladder side of the fistula. Indwelling Foley catheter placement alone is typically sufficient for bladder healing. Only when there are overt defects into the bladder should formal repair be undertaken.     

Diagnosis and management of enterovesical fistulas in patients with Crohn's disease

The objective of this study was to investigate the clinical manifestations and diagnostic studies used to evaluate Crohn's patients with enterovesical fistulas (EVFs) and to assess outcome after surgical intervention. This is a ten year multi-institutional retrospective chart review of patients with Crohn's disease. Of 400 patients identified with Crohn's disease eight (2%) were diagnosed with EVF. The mean age at diagnosis was 27 years. No patients had prior surgeries for Crohn's. Duration of symptoms ranged from 6 months to 15 years. There were seven ileovesical and one colovesical fistula identified. One patient had associated perianal disease. Three had concomitant enteroenteral fistulae. Clinical features included pneumaturia in seven patients (88%), fecaluria in three (38%), hematuria in five (63%), and urinary tract infection symptoms in seven (88%). Diagnostic studies included CT scan in six, barium or gastrografin enema in four, and cystoscopy in four. Surgical therapy involved resection of the affected bowel. The bladder defect was closed primarily in two layers in all patients using absorbable suture, with omental patch in four. Two patients underwent ileostomy and one underwent colostomy, all taken down within 6 months. There were no bladder leaks and no anastamotic leaks. There were no perioperative deaths. The mean postoperative stay was nine days. The mean follow-up was 39 months. We conclude that pneumaturia is a strong clinical indicator of EVF. CT has been valuable in identifying gas within the bladder in these patients. Cystoscopy has proven useful in identifying the fistulous tract and in evaluation of the ureters. The presence of an EVF should heighten suspicion as to the presence of concomitant enteroenteral fistulae. Barium or gastrografin studies are useful in this capacity. Surgical treatment of EVFs should include resection of affected bowel. The bladder defect can safely be closed using absorbable suture.     

Ileovesical fistula complicating Crohn's disease: a case report

A 43-year-old woman was admitted on October 6, 1987 with the chief complaint of fecaluria, pneumaturia and miction pain. She had been diagnosed as Crohn's disease in March, 1987. Urinalysis revealed numerous leucocytes, and streptococcus faecium was identified by urine culture. Contrast film of small intestines showed ileovesical fistula arising from terminal ileum. Cystoscopy revealed a papillary tumor-like appearance at the dome of the bladder. An operation was performed on November 9 under the diagnosis of ileovesical fistula complicating Crohn's disease. It was found that ileal region formed a hard adhesion to the bladder wall. Partial resection of the ileum and bladder was performed. Ileovesical fistula was found in the adhesion. Histological diagnosis of the affected ileum was Crohn's disease, showing noncaseating granuloma with the multinucleated giant cells. This case is the first report of female urological complication of the Crohn's disease in the Japanese literature.     

Enterovesical fistula caused by non-Hodgkin’s lymphoma of the ileum: report of a case

We herein present a rare case of enterovesical fistula caused by ileal non-Hodgkin’s lymphoma. A 75-year-old Japanese male presented with macrohematuria at Kosei General Hospital in December 2010. An egg-sized mass was palpable in his right lower abdominal region, and computed tomography (CT) revealed that the ileal tumor had invaded the right posterior wall of the urinary bladder (UB). A histopathological examination of a CT-guided needle biopsy specimen revealed diffuse large B-cell lymphoma involving the ileum and the UB. Thereafter, fecaluria appeared. A transurethral catheter was put in place, and there were no symptoms of cystitis. The patient received chemotherapy for the lymphoma, which produced a partial response. However, the fecaluria continued, and an examination of the small intestine with contrast revealed a thick and irregular wall of the ileum and a fistula between the ileum and UB. A partial resection of the ileum and a partial cystectomy were carried out in April 2011. The surgical specimen demonstrated two tumors 5 cm apart in the ileum, measuring 4.5 × 7 and 4 × 3 cm in size. The proximal tumor had directly invaded the UB and formed an ileovesical fistula. The patient made a good recovery and was doing well 5 months after the surgery without any evidence of recurrence.     

Metabolic acidosis during urinary retention in a patient with an enterovesical fistula

We report a patient known to have an enterovesical fistula who presented severe acute metabolic acidosis during an episode of urinary retention. The enterovesical fistula which had been intermittently symptomatic for 4 years, had developed after several intestinal surgical procedures and related intraperitoneal sepsis following resection of colon cancer 21 years previously. The patient who had a total colectomy and ileostomy, was admitted for hip replacement with the routine placement of a Foley bladder catheter. Three weeks post-operatively, the patient developed acute urinary retention following removal of the urinary catheter. The output from his ileostomy was immediately markedly increased, presumably from bladder urine diverted into the intestines through the enterovesical fistula. Within a few days he presented a normal anion gap metabolic acidosis with raised urea and stable creatinine; his clinical status deteriorated markedly with profound obtundation. These metabolic abnormalities were readily corrected by re-insertion of the Foley catheter with restoration of normal urine flow and immediate corresponding fall in the ileostomy output. Radiographic studies showed the presence of the enterovesical fistula originating from the jejunum. This is the first report of acute metabolic acidosis in association with an enterovesical fistula; the severe metabolic disturbances were triggered by the development of urinary retention resulting in the diversion of urine into the small bowel through the fistula.     

Management of enterovesical fistula in patients with Crohn's disease

PURPOSE: Enterovesical fistula in patients with Crohn's disease is intractable. Although there are some reports that the enterovesical fistula were successfully treated conservatively, closure of the fistula cannot always be achieved and surgical intervention may required for those patients. Since surgical closure of entero-entero fistula has a high risk of relapse, the strategy for treating enterovesical fistula has not been established. We evaluated the clinical findings especially in management of enterovesical fistula in Crohn's disease. PATIENTS AND METHODS: Two hundred two patients (mean age was 28.4 year old, range 12-69; 152 men and 50 women) were diagnosed as Crohn's disease during a period of 15 years between 1986 and 2000 in our institute. The incidence and the clinical results regarding the diagnosis and the treatment of enterovesical fistula in these patients were retrospectively evaluated. RESULTS: Seven in 202 patients were diagnosed to have an enterovesical fistula (3.5%, 6 men and 1 woman). The period from the initial diagnosis of Crohn's disease to the recognition of the enterovesical fistula was 11 to 204 months (mean 92.1 months). Enterovesical fistula was revealed and/or visualized by radiological enterography in 6, cystography in 2, cystoscopy in 6, and CT in 4 patients. Surgical interventions were finally conducted in all 7 patients after the failure of conservative treatment for 10 to 146 days (mean 68.2 days). Surgical procedures performed for closing the enterovesical fistula were partial cystectomy with fistulectomy in 5, fistulectomy with bladder wall overlay-suture in 2, and bladder wall overlay-suture alone in 1. No relapse of enterovesical fistula was recognized in any patient in the average observation of 41.6 months. CONCLUSION: Although the treatment of Crohn's disease has been advanced, enterovesical fistula is shown to be resistant to conservative treatment options and it makes patients in unfavorable status for relatively long duration. Our evaluation shown here demonstrated the sufficient surgical results on the closure of enterovesical fistula without any relapse, and was different from the high relapse rate after the surgical management of entero-entero fistula in similar observation period. Surgical interventions of enterovesical fistula caused by Crohn's disease might have an advantage to make diseased patients improved in shorter duration.     

Vesico-diverticular fistula: a rare complication of Meckel's diverticulum.

Enterovesical fistulas usually result from diverticulitis, Crohn's disease, or colorectal cancer. A perforated Meckel's diverticulum can also result in an vesico-diverticulum fistula, as noted in three previously reported cases. In all three cases, bladder or bowel disease was associated with the fistula. Herein, the authors describe a previously healthy, 23-year-old man who presented with an enterovesical fistula. Exploratory laparotomy revealed a vesico-diverticular fistula resulting from a perforated Meckel's diverticulum. Pathologic examination revealed that the diverticulum did not contain ectopic gastric or pancreatic tissue and that the perforation was secondary to an enterolith. The patient underwent a diverticulectomy and had an uneventful postoperative course. Unlike any of the three previously reported cases, the authors' patient had no coexisting bowel or bladder disease occurring with his vesico-diverticular fistula. To the authors' knowledge, this is only the third reported case of a vesico-diverticular fistula resulting from a perforated Meckel's diverticulum that did not contain ectopic tissue. It represents the first case where the perforation was secondary to an enterolith.     

Vesicocolonic fistula four years after augmentation colocystoplasty.

An 8-year-old girl was born with crossed fused renal ectopia and neurogenic bladder due to sacral agenesis. Due to progressive upper tract deterioration and incontinence despite clean intermittent catheterization and pharmacotherapy with anticholinergic agents, the patient underwent augmentation colocystoplasty at the age of 4 years. Four years after surgery the girl was readmitted because of persistent febrile urinary tract infection, persistent metabolic acidosis, and intermittent watery diarrhea. A cystogram revealed a fistula between the dome of the augmented bladder and the transverse colon. The fistula was successfully resected. The presence of enterovesical fistula should always be suspected in a patient with augmented bladder who have late onset of urinary tract infection, metabolic acidosis, and diarrhea.     

A case of cecovesical and rectovesical fistulas secondary to mucinous adenocarcinoma of the cecum

A hundred and nine cases of cecovesical fistula are described in the literature. Although its origin is usually reported to be appendicitis, we present a rare case of cecovesical and rectovesical fistulas secondary to mucinous adenocarcinoma of the cecum. An 84-year-old man was referred to our hospital with the chief complaints of fever and cloudy urine. An enterovesical fistula was seen on cystography, and cystoscopy showed a lot of mucinous fluid in the bladder and the papillary tumor arising from the enteric mucosa was identified through the fistula. Transurethral biopsy of the tumor revealed a mucinous adenocarcinoma of suspected colonic origin. At the operation, cecovesical and rectovesical fistulas secondary to cecal tumor were removed by right hemicolectomy, low anterior resection of the rectum and partial cystectomy.     

Management of urinary complications in Crohn's disease

Among the 127 patients who underwent surgical treatment for Crohn's disease at Tohoku University Hospital, urinary complications were noted in 13 patients (10.2%), including urolithiasis in 6 patients (4.7%), a ureteral obstruction in 4 (3.1%), and urinary fistula in 3 (2.4%). In patients with urolithiasis, conservative therapy was effective. An ureteral obstruction was detected on the right side in all 4 of these cases because of the inflamed terminal ileum. In 2 of the 4 cases, the symptoms improved by either preoperative total parenteral nutrition or elemental diet therapy. A resection of the inflamed intestine was necessary in all cases. In patients with urinary fistulas, a resection of the inflamed intestine combined with a reconstruction of the urinary tract was carried out after total parenteral nutrition. In conclusion, conservative therapy with preoperative total parenteral nutrition or elemental diet therapy proved to be effective for a ureteral obstruction since it improved the intestinal inflammation. As a definitive treatment, surgery is still necessary for the management of urinary fistulas and ureteral obstruction. Based on our findings, patients with urolithiasis in Crohn's disease should thus be treated conservatively in the same way as patients without Crohn's disease.     

Vesicorectal fistula associated with Crohn's disease: a case report

A 41-year-old man was hospitalized, complaining of fecaluria and right lower abdominal pain. He was diagnosed to have vesicorectal fistula. Wedge resection of bladder and rectum, and partial resection of ileocecal legion were performed. Pathological diagnosis was Crohn's disease. Postoperative course was uneventful and no recurrence was observed. Including our case, 32 cases of enterovesical fistula due to Crohn's disease have been reported in the Japanese literature.     

Course of enterovesical fistulas in Crohn's disease

Enterovesical fistulas occurred in 38 of 683 patients (5.6 percent) with Crohn's disease admitted to The Mount Sinai Hospital between 1960 and 1977. There were 22 ileovesical fistulas, 8 colovesical fistulas, and 8 fistulas of combined ileal and colonic origin. These cases fell into three different pathophysiologic categories: 16 patients presented with sepsis after a mean duration of 7 years of Crohn's disease, 19 presented without sepsis after a mean of 10 years of disease, and 3 elderly cancer patients presented with an average 25 years disease duration. Sepsis was usually due to deep pelvic or lower quadrant abscess with spontaneous rupture into the bladder. Nonseptic fistulization was a later, more gradual process, reflecting slow penetration into the bladder from a site of chronic cicatrizing bowel disease. Cancer was a very late complication, arising in each patient from an excluded loop. Although medical treatment was successful in delaying surgery in 6 patients and obviated surgery altogether in 2 patients, 36 of 38 patients (95 percent) eventually required operation. Postoperative mortality in this series was limited to two patients (5 percent) with preoperative intraabdominal abscess and sepsis. Five other deaths, unrelated to urinary complications, were caused by intestinal cancer in three patients and by intestinal complications of recurrent Crohn's disease in two patients. The urologic course of patients with enterovesical fistula was completely benign. All operated patients were cured of their enterovesical fistulas, and no urologic sequelae developed. Subsequent reoperations that were required in 45 percent of these patients were all for recurrent bowel disease and not for fistula or other urologic problems.     

Management of enterovesical fistulas

The records of 51 patients diagnosed with enterovesical fistulas at Virginia Mason Medical Center from 1974 to 1988 were reviewed. Diverticulitis (41%), Crohn's disease (17%), and colorectal cancer (16%) were the major causes. In 50 of 51 patients, the diagnosis was made on the basis of the clinical history and the urine culture. Radiologic and endoscopic studies failed to identify the fistula in 20%, though all were confirmed at operation or autopsy. In four of eight patients with fistulas secondary to colorectal cancer, malignancy was not diagnosed preoperatively. Operation was performed in 84% of the patients. One-stage resection of the bowel was performed in 66% of patients with the intent of removing the fistula. The complication rate was 8% with no deaths. All multi-stage procedures were performed for fistulas complicated by abscess or bowel obstruction. There were two postoperative deaths in patients with metastatic cancer undergoing palliative diversion. All eight patients treated by diverting colostomy had persistent fistulas and urinary sepsis. All eight patients treated with antibiotics but without operation were free of complications of the fistula until death from other causes. Enterovesical fistula is a clinical diagnosis. Preoperative studies should be used to delineate the bowel disease and search for malignancy rather than to see the fistula, which is clinically apparent. One-stage resection of the involved bowel is the procedure of choice in the absence of abscess or bowel obstruction. When resection is not feasible, medical management with antibiotics is preferable to colostomy.     

Ileovesical fistula due to Crohn's disease: a case report

A 24-year-old male first experienced pollakisuria, dysuria, pneumaturia and diarrhea in May 1988. Intravenous pyelography showed a normal upper urinary tract but bladder wall irregularity at the dome was observed. Cystoscopic examination revealed bullous edema, erythema and presence of a mucous-like substance. Barium enema X-ray examination revealed inflammatory changes at the terminal ileum but no fistulous connection was noted. Mild ulceration was observed on colon fiberscopic examination. At operation, a severely inflamed lower ileum firmly adherent to the dome of bladder as well as to the sigmoid colon was observed. Fistulous communication between bladder and ileum was also noted. Resection of diseased ileum, sigmoid colon and partial cystectomy were carried out. The patient remains well, without enteric or bladder symptoms.     

Ileovesical fistula caused by bladder cancer with bladder stone

Enterovesical fistula is a very rare complication of primary urological malignancies. A case of ileovesical fistula caused by a bladder carcinoma is presented. A 66-year-old male was referred with complaints of urinary pain. On admission, fecaluria and urinary tract infection with bladder stone were detected. Cystography revealed the passage of contrast medium into the small bowel. Under the diagnosis ofileovesical fistula due to suspected inflammatory disease, sigmoidectomy and segmental small bowel resection with partial cystectomy were performed. Histological evaluation revealed a poorly differentiated urothelial carcinoma. Without further treatment, the patient died from cancer five months after operation. However, it is hard to assess the effect of fistulas on prognosis. Since it has been reported that about 40% of the patients with T4 bladder tumors could be potentially cured with radical resection, we recommend a thorough examination to confirm the diagnosis of primary disease to obtain the best results.     

Recurrent Crohn's disease in the ileocolonic anastomosis complicated with duodenal fistula

Duodenal fistulas in patients with Crohn's disease are rare, and up to one hundred cases were described in the medical literature. We report an additional case of a 40-year-old male who underwent an ileo-ascending colectomy 13 years ago for Crohn's disease and was admitted to our unit with palpable abdominal mass and persistent cutaneous fistula. Preoperative fistulography and barium enema demonstrated Crohn's disease recurrence in the site of the ileocolonic anastomosis and external fistula communicating with the pre-anastomotic ileum. At surgery, Crohn's disease recurrence in the site of ileocolonic anastomosis with ileo-cutaneous fistula was confirmed and an additional ileo-duodenal fistula was detected incidentally. The patient underwent resection of the affected bowel and simple closure of the duodenal fistula with omental pedicle graft transposition between the duodenum and the ileocolonic anastomosis. Postoperative period was uneventful. We review the literature and discuss the incidence and treatment strategy of duodenal fistulas complicating recurrent Crohn's disease in the site of the ileocolonic anastomosis. The authors highlight that simple closure of the duodenal defects is appropriate only for small duodenal fistulas and omental transposition between ileo-colonic anastomosis and duodenum during the primary and repeated resection should be considered as an effective prevention method of duodenal fistulas formation.     

Enterovesical fistula due to Crohn's disease masquerading as bladder tumor

Enterovesical fistula as a complication of Crohn's disease is a rare condition. A case of Crohn's disease with ileovesical and rectovesical fistulas manifesting as bladder tumor is presented.     

Management of urinary complication in Crohn's disease

PURPOSE: Although urinary complications of Crohn's disease are relatively rare, they often present diagnostic and therapeutic dilemmas. However, there is no established strategy for treating urinary complications of Crohn's disease. In the present clinical study, we describe the frequency of urinary complications of Crohn's disease, and discuss various approaches to their diagnosis and treatment. PATIENTS AND METHODS: The subjects were 1,551 patients who underwent medical treatment for Crohn's disease between January 1994 and May 2002 at Social Insurance Central General Hospital. The subjects were retrospectively evaluated. RESULTS: Urinary complications occuered in 75 of the 1,551 patients (4.8%): urolitiasis in 60 patients, urinary fistula in 14 patients, and urachal abscess (Enterourachocutaneous fitulas) in 1 patient. A total of 41 of the 75 patients with urinary complications (55%) consulted a practicing urologist: 26 patients with urolithiasis, 14 patients with urinary fistula and 1 patient with urachal abscess. 26 patients with urolithiasis received medical treatment: 20 patients underwent conservative therapy, 4 patients underwent ESWL, and 2 patients underwent TUL. In all 26 of those cases, the treatment was successful. Twelve of the 14 patients with urinary fistulas (86%) underwent resection of the inflamed intestine combined with reconstruction of the urinary tract. The 1 patient with urachal abscess underwent resection of the urachus and the inflamed intestine, and partial cystectomy. CONCLUSION: All patients with urolithiasis should be treated the same way, whether or not they have Crohn's disease. In patients with Crohn's disease complicated by urinary fistula, surgery should be performed after preoperative medical therapy, as it improves the quality of life of such patients more rapidly than other approaches and may help avoid intestinal resection.