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ILEAL CONDUIT INTESTINAL FISTULA PRESENTING AS ACUTE RENAL FAILURE
0022-5347/00/1642-043910 TIIE JOURNAL OF UROLOGY@ Copyright 0 2000 by AMERICAN UROLOGICAL ASSOCIATION, INC.@
Vol. 164,439, August 2000 Printed in U.S.A.
ILEAL CONDUIT INTESTINAL FISTULA PRESENTING AS ACUTE RENAL FAILURE M. SHAFII, P. MOHAN, U. BEHAN, F. KEELING
AND
D. P. HICKEY
From the Departments of Urology and Transplantation, and Radiology, Beaumont Hospital, Dublin, Ireland
KEY WORDS: urinary diversion, fistula, kidney, kidney failure Urinary diversion can be associated with significant morbidity. A major complication is fistula formation.1 However, ileal conduit intestinal fistulas are rare. To our knowledge only 9 cases have been reported. We discuss a rare case of loopo-enteral fistula presenting as acute renal failure. CASE REPORT
A 62-year-old man presented with oliguria, watery diarrhea, central abdominal pain and vomiting 1 week in duration. History was remarkable for supravesical urinary diversion for the treatment of an intractable perineal fistula of unknown cause 2 years earlier. Physical examination revealed a soft, mildly tender and slightly distended abdomen with no rebound tenderness and normal bowel sounds. All of the previous tests were negative for Mycobacterium tuberculosis. Urea was 38.6 mmo1.A. (normal 2.5 to 8.51, creatinine 3.435 mg./dl. (normal 0.565 to 1.356),potassium 6.07 mmo1.A. (normal 3.2 to 5.2) and chloride 114 mmo1.A. (normal 98 to 108). Hydrogen ion concentration was 7.275 (normal 7.35 to 7.45), oxygen partial pressure (tension) 16.3 kPa. (normal greater than 10.6), carbon dioxide production 1.68 kPa. (normal 4.7 to 6), bicarbonate radicle 5.7 mmol.A., base excess - 17.9 and oxygen saturation 98%. Stool creatinine was 6,139 pmo1.A. White blood count was mildly elevated a t 11.3 X 109~. The patient was treated with sodium bicarbonate and normal saline infusion. Chest radiography was normal, and abdominal x-ray and computerized tomography revealed dilatated, fluid filled loops of small intestine. Loopogram demonstrated a fistula between the small intestine and ileal conduit (see figure). Diagnosis was ileal conduit intestinal fistula. At surgery the distended loops of small intestine were full of urine. A fistula was identified between the distal end of the conduit a t the site of ureteral implantation and distal ileum. The left ureter was dilated. The segment of small intestine containing the fistula was resected and re-anastomosed with a gastrointestinal anastomosis stapler, and the ureters were reimplanted into the conduit separately over stents. Blood chemistry studies returned to normal 2 days postoperatively. Diarrhea stopped and the patient was discharged home with a creatinine of 130 pmo1.A. At 3-month followup creatinine was 128 pmo1.A.
Loopogram shows fistula (arrows)between ileal conduit and small intestine (SO. LUR, left ureter. LP, loop of ileal conduit.
cluding 3 in the early postoperative period1 and 6 a t 9 months to 8 years postoperatively.2 Two patients underwent diversion for benign disease and the remainder underwent diversion for invasive bladder carcinoma. The predisposing factors were recurrent or residual malignancy, radiotherapy, diabetes mellitus, stoma1 stenosis, parastomal hernia, prolonged ileus, bowel obstruction and conduit calculi. Patients may present with diarrhea, oliguria and hyperchloremic metabolic acidosis. To our knowledge there have been no previous reports of this type of fistula presenting as acute renal failure. The cause of delayed fistula in our patient is unclear as he had not received radiation and other causes, such as tuberculosis and inflammatory bowel diseases, had been ruled out. Loopogram is the best investigative method, although 1 study demonstrated severe urosepsis after this procedure and the authors cautioned against its use.3 However, this complication has not been reported by others. Early fistulas have been treated with a conservative approach3 but late fistulas and those in which a conservative approach fails require surgical correction.
DISCUSSION
Ileal conduit intestinal fistula is rare. To our knowledge there have been only 9 cases reported in the literature, inAccepted for publication March 3, 2000.
439
REFERENCES
1. Kumar, S.and Grabstald, H.: Ileal conduit-jejunalfistula following cystectomy and urinary diversion. J Urol, 114: 466, 1975 2. McCallion, W. A., Wilson, B. G., Kennedy, J. A. et al: Ileal conduit-enteric fistula. Br J Urol, 71: 230, 1993 3. Nieh, P. T.and Parkhurst, E. C.: Successful management of ileal conduit-enteric fistula: the case against loopograms. J Urol, 118: 112, 1977
Vol. 164,439, August 2000 Printed in U.S.A.
ILEAL CONDUIT INTESTINAL FISTULA PRESENTING AS ACUTE RENAL FAILURE M. SHAFII, P. MOHAN, U. BEHAN, F. KEELING
AND
D. P. HICKEY
From the Departments of Urology and Transplantation, and Radiology, Beaumont Hospital, Dublin, Ireland
KEY WORDS: urinary diversion, fistula, kidney, kidney failure Urinary diversion can be associated with significant morbidity. A major complication is fistula formation.1 However, ileal conduit intestinal fistulas are rare. To our knowledge only 9 cases have been reported. We discuss a rare case of loopo-enteral fistula presenting as acute renal failure. CASE REPORT
A 62-year-old man presented with oliguria, watery diarrhea, central abdominal pain and vomiting 1 week in duration. History was remarkable for supravesical urinary diversion for the treatment of an intractable perineal fistula of unknown cause 2 years earlier. Physical examination revealed a soft, mildly tender and slightly distended abdomen with no rebound tenderness and normal bowel sounds. All of the previous tests were negative for Mycobacterium tuberculosis. Urea was 38.6 mmo1.A. (normal 2.5 to 8.51, creatinine 3.435 mg./dl. (normal 0.565 to 1.356),potassium 6.07 mmo1.A. (normal 3.2 to 5.2) and chloride 114 mmo1.A. (normal 98 to 108). Hydrogen ion concentration was 7.275 (normal 7.35 to 7.45), oxygen partial pressure (tension) 16.3 kPa. (normal greater than 10.6), carbon dioxide production 1.68 kPa. (normal 4.7 to 6), bicarbonate radicle 5.7 mmol.A., base excess - 17.9 and oxygen saturation 98%. Stool creatinine was 6,139 pmo1.A. White blood count was mildly elevated a t 11.3 X 109~. The patient was treated with sodium bicarbonate and normal saline infusion. Chest radiography was normal, and abdominal x-ray and computerized tomography revealed dilatated, fluid filled loops of small intestine. Loopogram demonstrated a fistula between the small intestine and ileal conduit (see figure). Diagnosis was ileal conduit intestinal fistula. At surgery the distended loops of small intestine were full of urine. A fistula was identified between the distal end of the conduit a t the site of ureteral implantation and distal ileum. The left ureter was dilated. The segment of small intestine containing the fistula was resected and re-anastomosed with a gastrointestinal anastomosis stapler, and the ureters were reimplanted into the conduit separately over stents. Blood chemistry studies returned to normal 2 days postoperatively. Diarrhea stopped and the patient was discharged home with a creatinine of 130 pmo1.A. At 3-month followup creatinine was 128 pmo1.A.
Loopogram shows fistula (arrows)between ileal conduit and small intestine (SO. LUR, left ureter. LP, loop of ileal conduit.
cluding 3 in the early postoperative period1 and 6 a t 9 months to 8 years postoperatively.2 Two patients underwent diversion for benign disease and the remainder underwent diversion for invasive bladder carcinoma. The predisposing factors were recurrent or residual malignancy, radiotherapy, diabetes mellitus, stoma1 stenosis, parastomal hernia, prolonged ileus, bowel obstruction and conduit calculi. Patients may present with diarrhea, oliguria and hyperchloremic metabolic acidosis. To our knowledge there have been no previous reports of this type of fistula presenting as acute renal failure. The cause of delayed fistula in our patient is unclear as he had not received radiation and other causes, such as tuberculosis and inflammatory bowel diseases, had been ruled out. Loopogram is the best investigative method, although 1 study demonstrated severe urosepsis after this procedure and the authors cautioned against its use.3 However, this complication has not been reported by others. Early fistulas have been treated with a conservative approach3 but late fistulas and those in which a conservative approach fails require surgical correction.
DISCUSSION
Ileal conduit intestinal fistula is rare. To our knowledge there have been only 9 cases reported in the literature, inAccepted for publication March 3, 2000.
439
REFERENCES
1. Kumar, S.and Grabstald, H.: Ileal conduit-jejunalfistula following cystectomy and urinary diversion. J Urol, 114: 466, 1975 2. McCallion, W. A., Wilson, B. G., Kennedy, J. A. et al: Ileal conduit-enteric fistula. Br J Urol, 71: 230, 1993 3. Nieh, P. T.and Parkhurst, E. C.: Successful management of ileal conduit-enteric fistula: the case against loopograms. J Urol, 118: 112, 1977