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Year : 2004  |  Volume : 14  |  Issue : 4  |  Page : 409-412
Colo-vesical and colo-enteric fistulae in sigmoid diverticular disease - a case report


Department Of Radiology, Medwin Hospitals Nampally Hyderabad - 500 001 (Andhra Pradesh), India

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Keywords: Sigmoid diverticulae, diverticulitu, Colo-vesical fistula, Colo-enteric fistula

How to cite this article:
Chinchure D D, Rayudu B, Prasad V. Colo-vesical and colo-enteric fistulae in sigmoid diverticular disease - a case report. Indian J Radiol Imaging 2004;14:409-12

How to cite this URL:
Chinchure D D, Rayudu B, Prasad V. Colo-vesical and colo-enteric fistulae in sigmoid diverticular disease - a case report. Indian J Radiol Imaging [serial online] 2004 [cited 2019 Nov 15];14:409-12. Available from: http://www.ijri.org/text.asp?2004/14/4/409/28683

   Introduction Top


Diverticulae of the colon are acquired herniations of mucosa and sub mucosa. It is a common disorder of elderly and most commonly occurs in sigmoid colon. The diagnosis of sigmoid diverticulitis is often clinical. However imaging plays a very important role. Various complications of sigmoid diverticulae have been described. Fistula formation being one of them and often requires surgery. Contrast enema is invaluable in the diagnosis of this condition and scores over CT in its accurate demonstration of fistulous tracks. We report a case sigmoid diverticular disease that was found to have Colo-vesical and Colo-enteric fistulae.


   Case report Top


A seventy year old man presented with complaints of foul smelling urine and pneumaturia of three months duration. He had history of having undergone transurethral resection of prostate (TURP) six years back. However there was no history of lower abdominal pain in the past. Clinically he was suspected to have rectovesical fistula. Urine examination revealed plenty of pus cells and grew Klebsiella pneumoniae. He was admitted to another hospital where cystoscopy revealed the presence of fecal material in the urinary bladder; however no fistulous opening could be demonstrated. The micturating cystourethrogram (MCU) was performed and was reported as normal [Figure - 1] & [Figure - 2].

He was referred to our department for US and barium enema examination. US showed presence of echogenic debris in the urinary bladder possibly representing fecal matter [Figure - 3]. Subsequently the patient underwent barium enema examination, which revealed presence of multiple small diverticulae along sigmoid colon [Figure - 4]. The lumen of sigmoid colon was narrowed. We could demonstrate two separate fistulous tracks from sigmoid colon to the urinary bladder and one of the distal ileal loops [Figure - 5] & [Figure - 6]. The diagnosis of colo-vesical and colo-enteric fistulae due to sigmoid diverticular disease was offered. Meanwhile the patient underwent colonoscopy, which showed narrowed sigmoid colon with diverticulae.

The patient underwent surgery and was found to have densely adherent sigmoid colon and posterior wall of the urinary bladder, which were separated [Figure - 7]. Sigmoid colectomy and primary end to end anastomosis of lower descending colon and upper rectum was performed. The gross specimen shows grossly thickened wall of sigmoid colon with narrowed lumen due to chronic inflammation [Figure - 8]. Post operatively the patient did well and has improved and is symptom free on follow up.


   Discussion Top


Diverticular disease is the expression which describes a disorder most common in the sigmoid colon; there is a consistent abnormality of the muscularis propria and diverticula are usually, but not invariably, present. (Morson and Dawson, 1979).The sigmoid diverticula are acquired herniatons of mucosa and submucosa through the circular muscle layer at the points where blood vessels penetrate the colonic wall. Diverticula tend to occur in rows on either side of the colon between mesenteric and the respective antimesenteric taeniae. The condition may be asymptomatic, as in the majority of cases, or symptomatic, uncomplicated or complicated by the development of inflammation, obstruction or hemorrhage. Diverticulosis means simply the presence of diverticula and the term diverticulitis is only used when there is proven inflammation associated with the diverticula. Accurate descriptions of the morbid anatomy of diverticular disease were published in the first part of nineteenth century. Howship described the `convoluted folds' of the mucosa and the `cartilage'-like texture of the bowel wall in 1824. Cruveilhier was the first to give a detailed description of the diverticula in 1849 [1].

Diverticular disease of the sigmoid colon is an increasingly common clinical problem in the older age groups, particularly in the West, being present in 1/3rd of those over 60 years and 2/3rd over 80 years.

The mechanism of how these diverticula are produced is controversial. The following are usually incriminated-

a) Abnormal contractions in the sigmoid colon.

b) Chronic constipation.

c) Hypertrophy of bowel musculature.

d) Diet - low residue diet

e) Deposition of elastin in taeniae leading to contracture and shortening of bowel.

In about5% of cases this disease may be associated with gall stones and hiatus hernia (Saints triad). Diverticulosis itself is an asymptomatic condition. Its main two complications are bleeding and inflammation (diverticulitis). The diagnosis of sigmoid diverticulitis is often clinical and the features are localized pain and guarding in the left lower abdomen, fever, leucocytosis and raised ESR. High resolution US plays very important role in the diagnosis of sigmoid diverticulitis [2]. The CT criteria for the diagnosis of diverticulitis include - focal colonic wall thickening (more than three to five mm), linear to confluent paracolic soft tissue changes, paracolic abscess [3]. Heverhagen et al studied 20 suspected cases of acute diverticulitis by MRI. Short Tau Inversion Recovery (STIR) and true Fast Imaging Steady State Precession (FISP) images were studied. STIR images demonstrated oedema, pericolic exudation and ascites better, whereas true FISP images were better for segmental narrowing of colon. However MRI has limited sensitivity for small bubbles of air and a collection of extra luminal air can be missed [4],[5].

The complications of diverticulosis are,

a) Diverticulitis

b) Para colic abscess

c) Perforation

d) Fistula formation

e) Obstruction

f) Haemorrhage

g) Giant cyst formation.

The natural course of the disease in 80% of the cases is as follows [2] [Figure - 9].

Stage 0: Neck of the diverticulum becomes obstructed, followed by high intra diverticular pressure and impaired defence system against bacteria lodging in the fecolith. The surrounding mesenteric and omental fat gets inflammed and tries to wall off the imminent perforation.

Stage 1: Development of small paracolic abscess (often less than one cm), which are successfully walled off by mesentery and omentum. The fecolith usually disintegrates and sigmoid colon wall is locally weakened.

Stage 2: Evacuation of pus and residual fecal matter through weakened sigmoid wall into the colonic lumen through the original diverticular neck. At this stage, patient's symptoms resolve.

Stage R: Residual abnormalities remain fairly long after the resolution of symptoms.

In the rest of 20% diverticulitis takes complicated course [Figure - 10]. Free perforation without any sealing off by mesentery or omentum is relatively rare. Even in abscess more than 2.5cm in size, evacuation into colonic lumen remains the rule. The spill of fecal material or pus into peritoneal cavity leads to severe peritonitis or secondary abscess formation. The other less favourable sites of evacuation of para colic abscess are,

a) Neighbouring diverticula giving rise to longitudinally oriented abscess undermining the colonic wall. They heal badly causing recurrent inflammation and stenosis.

b) Evacuation into the urinary bladder or vagina causing fistulae

Fistula formation is one of the common complications of sigmoid diverticulitis and often requires surgery. The chronic inflammation due to diverticulitis leads to adhesions and sealing off of the collection which discharges into adjacent structures. Fistulae from sigmoid colon to urinary bladder and vagina are commonest, others being colo-enteric and colo-cutaneous fistulae. Colovesical fistula accounts for 10% of surgical cases of diverticulitis. The patient presents usually with pneumaturia and recurrent urinary tract infection.

Water soluble contrast rather than barium should be used in investigating acute cases. Contrast enema is superior to CT in demonstrating fistulous tracts to the urinary bladder, vagina, small bowel or abdominal wall. Fistulous tracts can be demonstrated in upto70% of cases. The water soluble contrast examination / barium enema examination also confirms the presence of diverticular disease, demonstrates its extent and excludes other causes of fistula, such as Crohn's disese and Carcinoma. Air in the urinary bladder is visible in up to 30% cases on plain radiographs. CT indirectly suggests presence of fistula to urinary bladder or vagina by showing air in these structures along with adjacent inflammatory changes in the form of focal thickening of urinary bladder wall and abscess interposed between bowel and bladder. In nut shell CT is better for suggesting the possibility of fistula, but contrast studies are better for depicting these fistulae [6].

Initially medical treatment should be tried in all cases of uncomplicated diverticulitis and the indications of surgical therapy are, if the patient does not respond promptly to medical treatment, recurrent acute diverticulitis, diverticulitis with complications and when carcinoma cannot be ruled out.


   Acknowledgements Top


The authors would like to thank Dr. MG Rama Rao, Dr. KVVN Raju and Dr. NP Padmakar for their help.

 
   References Top

1.Whiteway J, Morson BC. Pathology of ageing - Diverticular disease. Clin in Gastro 1985; 14: 829-846  Back to cited text no. 1  [PUBMED]  
2.Julien BCM. Ultrasonography of acute abdomen: gastrointestinal conditions. Radiol Clin N Am 2003; 41: 1227-1242  Back to cited text no. 2    
3.Courtney CN, van Sonnenberg E. CT of diverticulitis - diagnosis and treatment. Radiol Clin N Am 1989; 27: 743-752  Back to cited text no. 3    
4.Pedrosa I, Rofsky NM. MR imaging in abdominal emergencies. Radiol Clin N Am 2003; 41: 1243-1273   Back to cited text no. 4  [PUBMED]  
5.Heverhagen JT, Ishaque N, Zielke A, Bohrer T, El-Sheik M, Klose KJ. Acute colonic diverticulitis: visualization in magnetic resonance imaging. Magn Reson Imaging 2001; 19: 1275-1277  Back to cited text no. 5  [PUBMED]  
6.Rubesin SE, Lwvine MS. Radiologic diagnosis of gastrointestinal perforation. Radiol Clin N Am 2003; 41: 1095-1115  Back to cited text no. 6    

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Correspondence Address:
D D Chinchure
Department Of Radiology, Medwin Hospitals Nampally, Hyderabad - 500 001(Andhra Pradesh)
India
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Source of Support: None, Conflict of Interest: None


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    Figures

[Figure - 1], [Figure - 2], [Figure - 3], [Figure - 4], [Figure - 5], [Figure - 6], [Figure - 7], [Figure - 8], [Figure - 9], [Figure - 10]



 

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    Introduction
    Case report
    Discussion
    Acknowledgements
    References
    Article Figures

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