Diverticulitis with colovesical fistula

Case contributed by Dr Michael P Hartung

Presentation

Pneumaturia, fecaluria.

Patient Data

Age: 80 years
Gender: Male

Colonic diverticulosis.

Extensive irregular wall thickening and hyperenhancement of a short segment of the distal sigmoid colon with pericolonic inflammation.

A thin, fistulous tract can be seen extending from the inflamed sigmoid colon into a round collection abutting and invading into the bladder wall distorting the contour and containing mostly fluid and a few small locules of air. This communicates with a tiny defect in the bladder mucosa, and represents the point of fistulous communication with the bladder lumen (see annotated images).

Inflammatory bladder wall thickening and mucosal hyperenhancement with a small amount of intraluminal air.

Annotated images

Annotated images defining the fistulous tract. 

Operative note excerpt:

Further dissection along the mesentery of the sigmoid colon posteriorly on each side was carried dissection down into the pelvis where there was adherent inflammation between the sigmoid colon and the bladder. There was no evidence of any encroachment into the bladder that we dissected in, but we did see fistula formation and some purulent drainage from the sigmoid diverticula and chronic abscess area. We opened this, dissected the sigmoid colon on each side down to this part, taking down the mesentery using clamp-and-tie technique as well as the Ligasure. Once we had freed up past the point of the bladder and the inflammatory tissue, we came across the base of his using a curved reticulating stapler with a blue load and fired across this, taking care to avoid the ureters laterally and posteriorly on each side. There was dense inflammatory tissue in this area.

Once this distal staple line was fired, the specimen was freed. This was passed off to pathology as sigmoid colon.

We irrigated the pelvis, suctioned it dry. Sutures were placed where venous backflow was seen.

Pathology report:

GROSS DESCRIPTION:
Specimen "A" - Specimen received unfixed labeled sigmoid colon consists of a colon
segment measuring 15 x 4.5 cm. There is exudate along the surface and a few defects, one
of which is probe patent to the lumen, located 2 cm from one margin. On opening,
diverticula are seen leading toward the surface and covered by exudate. ? lesions are
identified. Representative sections as follows:
A1 - Proximal and distal margin.
A2-3 - Area of gross perforation.
A4 - Additional diverticulum/empyematous area.
A5 - Fibrotic pericolonic fat and additional area of possible perforation with
exudate.
A6 - Pericolonic lymph nodes (8).

FINAL DIAGNOSIS:
"A" - Sigmoid colon, resection -
-Diverticulosis and diverticulitis with areas of perforation consistent with fistula
tract.
-Diverticulosis with abscess
-Pericolonic lymph nodes, no significant abnormality.

Case Discussion

This patient had a history of colonic diverticulitis in the past, but no recent memory of acute pain symptoms prior to presentation for this study. The colonic wall thickening is worrisome for adenocarcinoma, but pathology was benign in this case.

What makes this case particularly impressive is the well-defined fistulous tract from the colonic lumen into an extraluminal collection, and through a small defect in the bladder mucosa (reference the annotated images). Additionally, the presence of air within the bladder wall strongly suggests the presence of fistula (which was strongly suspected based on the presentation of pneumaturia and fecaluria).

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Case information

rID: 59441
Published: 11th Apr 2018
Last edited: 14th Aug 2019
Inclusion in quiz mode: Included

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