Year : 2004 | Volume
: 14 | Issue : 3 | Page : 295--297
Case Report : Tubercular reno-colic fistula
G Singh, L Gordon-Harris
UN Hospital, UNAMSIL, Freetown, Sierra Leone, West Africa
Radiologist, 158 Base Hospital, C/o 99 APO, India
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Singh G, Gordon-Harris L. Case Report : Tubercular reno-colic fistula.Indian J Radiol Imaging 2004;14:295-297
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Singh G, Gordon-Harris L. Case Report : Tubercular reno-colic fistula. Indian J Radiol Imaging [serial online] 2004 [cited 2019 Aug 25 ];14:295-297
Available from: http://www.ijri.org/text.asp?2004/14/3/295/28606
A fistula between the kidney and the alimentary tract is uncommon. The reno-colic type is the most common with the disease process invariably originating in the kidney. Very rarely the aetiology is found to be in the colon. We encountered one such patient in whom a tubercular lesion of the colon caused a reno-colic fistula.
A 30 year old Corporal of the Sierra Leone Army, who had been detected to be HIV positive a year earlier, was admitted to our hospital with unquantified loss of weight, intermittent low grade fever and diarrhoea of three weeks duration. No significant past medical history was forthcoming. During the hospital stay the patient had occasional abdominal bloating, typical large bowel diarrhoea and an episode of rectal bleeding.
Physical examination revealed a poorly nourished patient who had anaemia. Systemic Examination did not reveal any obvious finding. Laboratory studies showed normochromic, normocytic anaemia and stool culture did not yield any organism.
A Double Contrast Barium Enema Study revealed mucosal irregularity with multiple diverticuli and ulcerations in the region of the splenic flexure of colon. Also there was an oval lesion of kidney size in the region of the left renal fossa, which was showing an air - fluid - barium level. This led to a suspicion of reno-colic fistula on the left side [Figure 1].
The next day Ultrasound examination was performed (Siemens Prima, Issaqua) with 5 MHz electronic sector probe and 7.5 MHz high-resolution linear probe. The scan revealed mild free fluid in the abdominal cavity [Figure 2]. The right kidney was normal in outline and position with a normal cortical echotexture and maintained cortico-medullary differentiation and no obvious abnormality. A kidney shaped cystic structure having thin regular walls occupied the left renal fossa [Figure 3]. This structure again showed an air - fluid - barium level [Figure 4]. The proximal descending colon was seen to be in relation to the lateral aspect of the superior pole of this left renal fossa cystic structure, which apparently was the left kidney. The colon at this site showed wall thickening and irregularity with associated mesenteric lymphadenopathy in the vicinity of the colon [Figure 5]. The liver, gall bladder, spleen and pancreas had a normal size and echotexture with no obvious abnormality detected. There were no obviously enlarged retroperitoneal lymph nodes.
A chest radiograph was normal.
Blood urea was normal. An intravenous urogram done a few days later showed a small amount of barium residue overlying the left renal area with a non-functioning left kidney. The right kidney showed a normal excretory function [Figure 6]. A Barium Meal Follow through examination was normal.
The patient was operated upon after improvement in his nutritional status. A fistula lined by granulomatous tissue was found communicating between a thickened and ulcerated proximal portion of the descending colon and the supero-lateral aspect of the left kidney, both of which were adherent to each other. The left kidney had been reduced to a thin smooth bag of fluid. Few lymph nodes were found in the proximal descending colon mesentery. A left nephrectomy with resection of the fistula and the diseased part of transverse and descending colon with primary repair was undertaken.
The patient did well post-operatively.
The pathological examination revealed the specimen large bowel wall to be moderately thick with marked superficial mucosal ulceration. Cut surfaces of the bowel wall showed focal outpouching areas consistent with diverticular disease. No tumour mass was noted within and around the bowel wall. Few small lymph nodes were identified in the mesentery. Histology of sections of large bowel showed severe mucosal ulceration with marked distortion of the glands. There was marked reactive hyperplasia of lymphoid follicles. Several large multinucleated giant cells and histiocytes were present with few well-formed epithelioid macrophages surrounded by lymphocytes with occasional central necrosis. There was no evidence of dysplasia or malignancy. The appearances were consistent with Tuberculous colitis. The kidney showed extreme cortical thinning with loss of parenchyma and infiltration by inflammatory cells.
The development of fistulous communication between the kidney and the alimentary tract is rare. In total there are about 130 reported cases. Reno-colic fistulae are the most common . The ascending and the descending colon are most frequently affected although the sigmoid colon and the caecum have been involved. The literature credits Hippocrates as reporting the first recorded case in 460 BC . In approximately 10% of reports there is associated cutaneous extension .
The aetiology is divided into traumatic and spontaneous. Traumatic cases form the minority and are invariably iatrogenic following open or percutaneous surgical procedure . Cases of reno-colic fistulae secondary to non-surgical treatment of blunt abdominal trauma have been documented . Spontaneous reno-colic fistulae almost always arise as a consequence of primary renal pathology. Underlying cause usually is renal tuberculosis or calculous pyonephrosis . Other known causes are non-calculous pyonephrosis, perinephric abscess and rupture of hydronephrosis. Renal malignancy and papillary necrosis have been implicated in a small number of cases.
Unlike in lower urinary tract fistulae, in which the primary cause is usually in the bowel, it is extremely unusual to find a colonic origin for a reno-colic fistula .
The clinical signs of a reno-colic fistula are rarely diagnostic though pneumaturia and pyuria might occur. The diagnosis is nearly always made radiologically either by barium enema or retrograde pyelogram due to the higher pressures generated from these procedures than generated in the renal collecting systems on intravenous urography . There is one report of a reno-colic fistula being diagnosed on intravenous urogram . Sometimes the diagnosis is made by CT scan or, if there is cutaneous extension, by fistulogram. In majority of the cases the affected kidney is non-functioning on excretion urography.
The mainstay of treatment is usually surgery with nephrectomy being usually necessary as the affected kidney is often completely destroyed and occasionally contains malignancy. Also there are reported cases of epidermoid carcinoma arising in a chronic reno-colic fistula .
In conclusion, a reno-colic fistula secondary to uncommon colonic etiology is reported. Barium enema, Ultrasonography and intravenous urogram helped in the diagnosis of the above condition.
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