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MDCT diagnosis of uterocutaneous fistula
European Journal of Radiology Extra 67 (2008) e129–e130
MDCT diagnosis of uterocutaneous fistula Gonca Eldem a , Baris Turkbey a,∗ , Sener Balas b , Erhan Akpinar a a
Hacettepe University School of Medicine, Department of Radiology, Sihhiye, Ankara 06100, Turkey b Hacettepe University School of Medicine, Department of General Surgery, Ankara, Turkey Received 12 February 2008; accepted 6 May 2008
Abstract Uterocutaneous fistula is a rarely seen entity mostly developing secondary to post-partum or postoperative complications. Contrast enhanced computed tomography (CT) may contribute to prompt diagnosis. We report a case of uterocutaneous fistula developed secondary to cesarean section performed 19 years ago with exquisite CT findings. © 2008 Elsevier Ireland Ltd. All rights reserved. Keywords: Uterocutaneous fistula; Chronic pelvic pain; MDCT
Although uterovesical, uterocolonic fistulae are not uncommon, uterocutaneous fistula is a rare entity, mostly seen after post-partum or postoperative complications. Other causes such as migration of laminaria tent and intrauterine contraceptive devices have also been described [1,2]. Herein we present a case of uterocutaneous fistula developed secondary to cesarean section performed 19 years ago. 1. Case report A 50-year-old female referred to emergency room with persistent abdominal pain ongoing for 2 days. One month ago, a focus abscess with 5 cm in diameter was detected on her Pfannenstiel incision site belonging to caesarean section performed 19 years ago. Her past medical history was negative except caesarean section operation. Abscess was drained under guidance of ultrasound in a single session via a fine needle aspiration and she was put on antibiotic therapy. After a symptom free 4-week period, her symptoms persisted and she referred to emergency room with focal abdominal pain on her incision site. Her vitals were stable and her physical examination was normal except diffuse abdominal tenderness. Her white blood cell count was 10,300 L−1 (normal range = 3600–10,000 L−1 ) and hemoglobin was 11.8 g/dL (normal range = 12.00–18.00 g/dL). Abdominal computed tomography (CT) was obtained with a prediagnosis of abscess recurrence and/or incisional hernia. ∗
Corresponding author. Tel.: +90 3123051188; fax: +90 3123112145. E-mail address: [email protected] (B. Turkbey).
1571-4675/$ – see front matter © 2008 Elsevier Ireland Ltd. All rights reserved. doi:10.1016/j.ejrex.2008.05.009
CT was performed in with a 2-detector row MDCT machine (Emotion Duo, Siemens, Erlangen, Germany), which included scanning after oral and intravenous contrast material (Iomeron 300/100, Bracco, Milan, Italy) administration at venous phase (70 s delay following intravenous contrast material administration). On axial CT images, a fistula tract was visualized between anterior aspect of uterus and the subcutaneous tissue of anterior abdominal wall at level of Pfannenstiel incision (Fig. 1). Adjacent to the fistula tract, a hyperdense area with a mean density of 41 Hounsfield units (HU) was visualized within the subcutaneous tissue and this was interpreted as either a hemorrhage area or a dens fluid collection. Additionally, around this hyperdense appearance, stranding secondary to inflammation and edema was detected in the fat tissue (Fig. 2). With these findings she was operated. At laporotomy, a fistula tract was seen and an abscess was detected. Fistula tract was excised; considering patient’s age and fertility expectation, total abdominal hysterectomy and bilateral salpingooferectomy was performed. Histopathologic examination was consistent with abscess formation and chronic inflammation; moreover bilateral salphingitis was seen. Histopathology revealed no evidence of endometriosis, tuberculosis or inflammatory bowel disease. Postoperative course was uneventful and patient was discharged after 7 days. One year follow was symptom free. 2. Discussion Fistulae involving uterus are usually uterovesical, uterocolonic. Uterocutaneous fistula is a rare entity. An uterovesical
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G. Eldem et al. / European Journal of Radiology Extra 67 (2008) e129–e130
Fig. 1. Contrast enhanced axial computed tomography image shows the fistula tract between uterus and subcutaneous tissue (arrow), adjacent inflammatory and edematous stranding are also seen.
with impaction of a loop of bowel into the tear, inflammatory processes such as spontaneous rupture of a periappendiceal or diverticulitis abscess simultaneously into the bowel and uterus, uterine or sigmoid carcinoma, ulceration and necrosis resulting in colouterine fistula, radiation therapy and obstetrics trauma during curettage with perforation of the uterine wall and bowel [5]. On the other hand, a very rare seen entity, uterocutaneous fistula usually results from post-partum or postoperative complications. Other causes of this condition include migration of intrauterine contraceptive devices [1,2]. Possible mechanisms described previously in the literature involving uterus are multiple previous abdominal operations, long-term stay of drains, incomplete closure of uterine incision during cesarean section, inflammation and wound dehiscence. Fistula formation secondary to endometriosis and tuberculosis were also described [6,7]. Most fistulae originate from trauma or some other type of inflammatory processes that disrupt the continuity of tissues involved [2]. Another case of uterocutaneous fistula described in the literature is secondary to an abscess caused by in situ left placenta after an abdominal pregnancy [8]. In our case, abscess probably developed secondary to recurrent genitourinary infections or chronic inflammation due to a left unresorbable suture during cesarean section procedure, this chronic irritation might have resulted in fistula formation. As a conclusion, although very rarely encountered, uterocutaneous fistula should be considered in female patients with chronic pelvic pain secondary to focal uterine abscess: additionally, intravenous contrast enhanced CT and sagittal reconstructions may contribute to reaching prompt diagnosis. References
Fig. 2. Contrast enhanced sagital reformatted computed tomography image shows the fistula tract (arrow) and hyperdense stranding secondary to inflammation and edema.
fistula is known to be a complication of lower segment type cesarean section, curettage, difficult vaginal delivery, high delivery via forceps and secondary to migration of an intrauterine contraceptive device [3]. Abdominal pregnancy leading to perforation of the anterior wall of uterus, gynecological injuries and genital tuberculosis are some other risk factors that can contribute to fistula formation [4]. Uterocolonic fistulae are seen after traumatic or spontaneous rupture of gravid uterus
[1] Shukla D, Pandey S, Pandey LK, Shukla VK. Repair of uterocutaneous fistula. Obstet Gynecol 2006;108:732–3. [2] Gupta SK, Shukla VK, Varma DN, Roy SK. Uterocutaneous fistula. Postgrad Med J 1993;69:822–3. [3] Ramamurthy S, Vijayan P, Rajendran S. Sonographic diagnosis of a uterovesical fistula. J Ultrasound Med 2002;21:817–9. [4] Porcaro AB, Zicari M, Zecchini Antoniolli S, et al. Vesicouterine fistulas following cesarean section: report on a case, review and update of the literature. Int Urol Nephrol 2002;34:335–44. [5] Sentilhes L, Foulatier O, Verspyck E, Roman H, Scotte M, Marpeau L. Colouterine fistula complicating diverticulitis: a case report and review of the literature. Eur J Obstet Gynecol Reprod Biol 2003;110:107–10. [6] Dragoumis K, Mikos T, Zafrakas M, Assimakopoulos E, Stamatopoulos P, Bontis J. Endometriotic uterocutaneous fistula after cesarean section A case report. Gynecol Obstet Invest 2004;57:90–2. [7] Malhotra D, Vasishta K, Srinivasan R, Singh G. Tuberculous uteroenterocutaneous fistula—a rare post-caesarean complication. Aust N Z J Obstet Gynaecol 1995;35:342–4. [8] Promsonthi P, Herabutya Y. Uterocutaneous fistula in term abdominal pregnancy. Eur J Obstet Gynecol Reprod Biol 2007;132:239–41.
MDCT diagnosis of uterocutaneous fistula Gonca Eldem a , Baris Turkbey a,∗ , Sener Balas b , Erhan Akpinar a a
Hacettepe University School of Medicine, Department of Radiology, Sihhiye, Ankara 06100, Turkey b Hacettepe University School of Medicine, Department of General Surgery, Ankara, Turkey Received 12 February 2008; accepted 6 May 2008
Abstract Uterocutaneous fistula is a rarely seen entity mostly developing secondary to post-partum or postoperative complications. Contrast enhanced computed tomography (CT) may contribute to prompt diagnosis. We report a case of uterocutaneous fistula developed secondary to cesarean section performed 19 years ago with exquisite CT findings. © 2008 Elsevier Ireland Ltd. All rights reserved. Keywords: Uterocutaneous fistula; Chronic pelvic pain; MDCT
Although uterovesical, uterocolonic fistulae are not uncommon, uterocutaneous fistula is a rare entity, mostly seen after post-partum or postoperative complications. Other causes such as migration of laminaria tent and intrauterine contraceptive devices have also been described [1,2]. Herein we present a case of uterocutaneous fistula developed secondary to cesarean section performed 19 years ago. 1. Case report A 50-year-old female referred to emergency room with persistent abdominal pain ongoing for 2 days. One month ago, a focus abscess with 5 cm in diameter was detected on her Pfannenstiel incision site belonging to caesarean section performed 19 years ago. Her past medical history was negative except caesarean section operation. Abscess was drained under guidance of ultrasound in a single session via a fine needle aspiration and she was put on antibiotic therapy. After a symptom free 4-week period, her symptoms persisted and she referred to emergency room with focal abdominal pain on her incision site. Her vitals were stable and her physical examination was normal except diffuse abdominal tenderness. Her white blood cell count was 10,300 L−1 (normal range = 3600–10,000 L−1 ) and hemoglobin was 11.8 g/dL (normal range = 12.00–18.00 g/dL). Abdominal computed tomography (CT) was obtained with a prediagnosis of abscess recurrence and/or incisional hernia. ∗
Corresponding author. Tel.: +90 3123051188; fax: +90 3123112145. E-mail address: [email protected] (B. Turkbey).
1571-4675/$ – see front matter © 2008 Elsevier Ireland Ltd. All rights reserved. doi:10.1016/j.ejrex.2008.05.009
CT was performed in with a 2-detector row MDCT machine (Emotion Duo, Siemens, Erlangen, Germany), which included scanning after oral and intravenous contrast material (Iomeron 300/100, Bracco, Milan, Italy) administration at venous phase (70 s delay following intravenous contrast material administration). On axial CT images, a fistula tract was visualized between anterior aspect of uterus and the subcutaneous tissue of anterior abdominal wall at level of Pfannenstiel incision (Fig. 1). Adjacent to the fistula tract, a hyperdense area with a mean density of 41 Hounsfield units (HU) was visualized within the subcutaneous tissue and this was interpreted as either a hemorrhage area or a dens fluid collection. Additionally, around this hyperdense appearance, stranding secondary to inflammation and edema was detected in the fat tissue (Fig. 2). With these findings she was operated. At laporotomy, a fistula tract was seen and an abscess was detected. Fistula tract was excised; considering patient’s age and fertility expectation, total abdominal hysterectomy and bilateral salpingooferectomy was performed. Histopathologic examination was consistent with abscess formation and chronic inflammation; moreover bilateral salphingitis was seen. Histopathology revealed no evidence of endometriosis, tuberculosis or inflammatory bowel disease. Postoperative course was uneventful and patient was discharged after 7 days. One year follow was symptom free. 2. Discussion Fistulae involving uterus are usually uterovesical, uterocolonic. Uterocutaneous fistula is a rare entity. An uterovesical
e130
G. Eldem et al. / European Journal of Radiology Extra 67 (2008) e129–e130
Fig. 1. Contrast enhanced axial computed tomography image shows the fistula tract between uterus and subcutaneous tissue (arrow), adjacent inflammatory and edematous stranding are also seen.
with impaction of a loop of bowel into the tear, inflammatory processes such as spontaneous rupture of a periappendiceal or diverticulitis abscess simultaneously into the bowel and uterus, uterine or sigmoid carcinoma, ulceration and necrosis resulting in colouterine fistula, radiation therapy and obstetrics trauma during curettage with perforation of the uterine wall and bowel [5]. On the other hand, a very rare seen entity, uterocutaneous fistula usually results from post-partum or postoperative complications. Other causes of this condition include migration of intrauterine contraceptive devices [1,2]. Possible mechanisms described previously in the literature involving uterus are multiple previous abdominal operations, long-term stay of drains, incomplete closure of uterine incision during cesarean section, inflammation and wound dehiscence. Fistula formation secondary to endometriosis and tuberculosis were also described [6,7]. Most fistulae originate from trauma or some other type of inflammatory processes that disrupt the continuity of tissues involved [2]. Another case of uterocutaneous fistula described in the literature is secondary to an abscess caused by in situ left placenta after an abdominal pregnancy [8]. In our case, abscess probably developed secondary to recurrent genitourinary infections or chronic inflammation due to a left unresorbable suture during cesarean section procedure, this chronic irritation might have resulted in fistula formation. As a conclusion, although very rarely encountered, uterocutaneous fistula should be considered in female patients with chronic pelvic pain secondary to focal uterine abscess: additionally, intravenous contrast enhanced CT and sagittal reconstructions may contribute to reaching prompt diagnosis. References
Fig. 2. Contrast enhanced sagital reformatted computed tomography image shows the fistula tract (arrow) and hyperdense stranding secondary to inflammation and edema.
fistula is known to be a complication of lower segment type cesarean section, curettage, difficult vaginal delivery, high delivery via forceps and secondary to migration of an intrauterine contraceptive device [3]. Abdominal pregnancy leading to perforation of the anterior wall of uterus, gynecological injuries and genital tuberculosis are some other risk factors that can contribute to fistula formation [4]. Uterocolonic fistulae are seen after traumatic or spontaneous rupture of gravid uterus
[1] Shukla D, Pandey S, Pandey LK, Shukla VK. Repair of uterocutaneous fistula. Obstet Gynecol 2006;108:732–3. [2] Gupta SK, Shukla VK, Varma DN, Roy SK. Uterocutaneous fistula. Postgrad Med J 1993;69:822–3. [3] Ramamurthy S, Vijayan P, Rajendran S. Sonographic diagnosis of a uterovesical fistula. J Ultrasound Med 2002;21:817–9. [4] Porcaro AB, Zicari M, Zecchini Antoniolli S, et al. Vesicouterine fistulas following cesarean section: report on a case, review and update of the literature. Int Urol Nephrol 2002;34:335–44. [5] Sentilhes L, Foulatier O, Verspyck E, Roman H, Scotte M, Marpeau L. Colouterine fistula complicating diverticulitis: a case report and review of the literature. Eur J Obstet Gynecol Reprod Biol 2003;110:107–10. [6] Dragoumis K, Mikos T, Zafrakas M, Assimakopoulos E, Stamatopoulos P, Bontis J. Endometriotic uterocutaneous fistula after cesarean section A case report. Gynecol Obstet Invest 2004;57:90–2. [7] Malhotra D, Vasishta K, Srinivasan R, Singh G. Tuberculous uteroenterocutaneous fistula—a rare post-caesarean complication. Aust N Z J Obstet Gynaecol 1995;35:342–4. [8] Promsonthi P, Herabutya Y. Uterocutaneous fistula in term abdominal pregnancy. Eur J Obstet Gynecol Reprod Biol 2007;132:239–41.