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  Table of Contents  
IMAGES IN NEPHROLOGY
Year : 2016  |  Volume : 26  |  Issue : 4  |  Page : 306-307
 

Spontaneous reno-colic fistula in an elderly patient


Department of Diagnostic Radiology, Khoo Teck Puat Hospital, Yishun 768828, Singapore

Date of Web Publication1-Jul-2016

Correspondence Address:
A Chawla
Department of Diagnostic Radiology, Khoo Teck Puat Hospital, 90 Yishun Central, Yishun 768828
Singapore
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0971-4065.167273

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How to cite this article:
Chawla A, Chinchure D, Subramanian M, Singh D. Spontaneous reno-colic fistula in an elderly patient. Indian J Nephrol 2016;26:306-7

How to cite this URL:
Chawla A, Chinchure D, Subramanian M, Singh D. Spontaneous reno-colic fistula in an elderly patient. Indian J Nephrol [serial online] 2016 [cited 2019 Sep 15];26:306-7. Available from: http://www.indianjnephrol.org/text.asp?2016/26/4/306/167273




A 67-year-old woman was referred from a nursing home with fever and abdominal discomfort. She had multiple admissions for cerebral strokes in the past. There was no history of renal impairment or bowel complaints. Ultrasound showed marked left hydronephrosis with air foci within the renal pelvis, raising suspicion for emphysematous pyelonephritis. A contrast-enhanced computed tomography (CT) scan of abdomen and pelvis confirmed markedly dilated left pelvicalyceal system with a few air bubbles. There was no urinary calculus or dilatation of the ureter, suggesting long standing pelvi-ureteric junction (PUJ) obstruction. Interestingly, a track was noted between the left kidney and the splenic flexure [Figure 1]a and [Figure 1]b. There was no abdominal lymphadenopathy, focal collection, peritonitis, or evidence of bowel inflammation or diverticular disease. There was no chest radiographic evidence of pulmonary tuberculosis. The sputum and urine tests for acid-fast bacilli were negative. No granulomas were identified in the liver or the spleen. Tumor markers were within normal limits. Percutaneous nephrostomy showed flow of contrast from left renal pelvis to splenic flexure [Figure 2]. A diagnosis of reno-colic fistula was made. Urine culture grew enterococci. Following the drainage and intravenous antibiotics, patient's general condition improved within 36h with resolution of symptoms. The patient was discharged to nursing home with nephrostomy catheter and on oral antibiotics (ciprofloxacin). At the 1-month follow-up, the patient was doing well. At this time, there was improvement in the overall condition with down-trending inflammatory markers. A follow-up CT scan was scheduled a month later; however, there was interval worsening of the patient's condition. The patient became drowsy and uncommunicative and the patient's relatives opted for palliative comfort care in an inpatient hospice and no further imaging was performed.
Figure 1: (a) Oblique sagittal image of computed tomography scan shows dilated left renal pelvis (asterisk) with a reno-colic fistula (white arrow). (b) Coronal computed tomography image shows dilated renal pelvis (asterisk) with an air bubble (white arrow) and reno-colic fistula (black arrow)

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Figure 2: Antegrade pyelography was performed immediately after percutaneous nephrostomy. The injected contrast opacifes the renal pelvis (white arrow) and demonstrates a fistula (arrowhead) with the splenic flexure of the colon (black arrow)

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Although first described by Hippocrates, a fistula between renal pelvis and colon is a rare entity. Reno-colic fistula usually results from penetrating trauma and less commonly from diverticular disease, colonic malignancy, or inflammatory bowel disease.[1],[2],[3],[4] Spontaneous fistula secondary to xanthogranulomatous pyelonephritis, pyonephrosis, and tuberculosis has been described in literature.[5],[6],[7] Our patient was presumed to have a PUJ obstruction and probably developed the fistula from chronic inflammation with superimposed infection, as a diagnosis of exclusion. This is a rather uncommon cause for reno-colic fistula. CT scan shows air in the urinary system in the cases of urinary fistula that can be mistaken for emphysematous infection. Injection of contrast via a nephrostomy catheter is the standard preoperative method to diagnosis reno-colic fistula. This case highlights the utility of multiplanar reconstruction capabilities of modern day CT scanners that can help in diagnosing the reno-colic fistula noninvasively.

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  References Top

1.
Agrawal N, Rao S, Rudd J. Reno-colic arterial fistula due to penetrating abdominal trauma. ANZ J Surg 2011;81:400.  Back to cited text no. 1
[PUBMED]    
2.
Appel R, Musmanno MC, Knight JG. Nephrocolic fistula complicating percutaneous nephrostolithotomy. J Urol 1988;140:1007-8.  Back to cited text no. 2
    
3.
Husted JW. An unusual case of pyelonephritis: Nephrocolic fistula owing to a ruptured colonic diverticulum. J Urol 1974;111:724-6.  Back to cited text no. 3
[PUBMED]    
4.
Burst RW Jr, Morgan AL. Reno-colic fistula secondary to carcinoma of the colon. J Urol 1974;111:439.  Back to cited text no. 4
    
5.
Borum ML. An unusual case of nephrobronchial and nephrocolonic fistula complicating xanthogranulomatous pyelonephritis. Urology 1997;50:443.  Back to cited text no. 5
    
6.
Mooreville M, Elkouss GC, Schuster A, Pearce AE, Rosen J. Spontaneous renocolic fistula secondary to calculous pyonephrosis. Urology 1988;31:147-50.  Back to cited text no. 6
    
7.
Marwah S, Garg S, Marwah N, Chaudhry D. Tubercular renocolic fistula: An unusual presentation. Clin J Gastroenterol 2012;5:347-50.  Back to cited text no. 7
    


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