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Case 325

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Female, 69-year-old, complains of elimination of gas and stool from the urethral ostium. She was recently hospitalized due to abdominal inflammatory disorder and received intravenous antibiotic therapy for 48 hours with home maintenance until the end of treatment 8 days ago. History of rheumatoid arthritis using etanercept. Computed tomography (CT) scan of the abdomen was performed, showing a colovesical fistula, and surgery was performed to correct the lesion.

Considering the history of the patient and the clinical examination, what is the most likely etiology for the presented picture?

a) Colorectal carcinoma

25%

b) Carcinoma of the bladder

25%

c) Crohn disease

25%

d) Complicated Diverticulitis

25%
   

Image Analysis

Image 1: Computed tomography of the abdomen and pelvis, axial section, lower pelvic level, after intravenous injection of iodinated contrast, portal phase. Sigmoid colon with small diverticula and thickened wall associated with small pericolic abscess (red arrow). Right ovarian cyst - incidental finding - yellow arrow.

 

Image 2: Computed tomography of the abdomen and pelvis, axial section, level of the acetabuli, after intravenous injection of iodinated contrast, late phase. Presence of intravesical gas (red arrow).

 

Image 3: Computed tomography of the abdomen coronal (A) and sagittal (B) reconstructions, after intravenous injection of iodinated contrast medium, portal phase. Sigmoid colon with small diverticula and thickened wall (yellow arrow). Presence of intravesical gas (red arrows).

Highlights

- The main etiology of VCF is complicated acute diverticulitis;

- Most common signs and symptoms: recurrent urinary tract infection, pneumaturia and fecaluria;

- The examination of choice for diagnosis is CT with oral or rectal contrast medium;

- The treatment is primarily surgical based on the etiology, anatomical location and clinical conditions of the patient.

References

- Doherty GM. CURRENT Diagnosis and Treatment Surgery. 14th edition. New York: McGraw-Hill Education, 2015.

- Strickland M, Burnstein M, Cohen Z. Colovesical fistulas. Post TW, ed. UpToDate. Waltham, MA: UpToDate Inc. Access on July 15th, 2018.

- Pemberton JH- Acute diverticulitis complicated by fistula formation. UpToDate 2017. Access on July 18th, 2018.

Authors

Eduardo José Paolinelli Vaz de Oliveira, 6th year medical student at Universidade Federal de Minas Gerais.

E-mail: eduardopaolinelli[at]gmail.com.br

 

Guilherme Carvalho Rocha, acadêmico do 3rd year medical student at Universidade Federal de Minas Gerais.

E-mail: guilhermecarvalhorocha[at]gmail.com

Supervisor

Dra. Magda Maria Profeta da Luz, Adjunct Professor, Department of Surgery, Medical School of UFMG, coloproctologist and coordinator of the Medical Residency in Coloproctology, Alpha Institute of Gastroenterology, Hospital das Clínicas, UFMG.

E-mail: coloproctolifecenter[at]gmail.com

Reviewers

Bruno Campos, Elaine Iwayama, Gabriella Shiomatsu, Ariádna Andrade, Prof. José Nelson M. Vieira e Profª. Viviane Santuari Parisotto Marino.

Test question

(MEDICAL RESIDENCE 2014 - MUNICIPAL HEALTH SECRETARIAT - SP) A 51-year-old man reports pelvic pain 7 days ago, accompanied by vomiting, anorexia and fever. Pain worsens with food. He refers pneumaturia, occurred two days ago. He denies weight loss. Previously healthy, there was no change in bowel habits. He never smoked. BMI = 35 kg / m². He is in regular general condition. Axillary temperature = 37.8 ° C. The abdomen is globose, with painful "mass" in the left iliac fossa. Main diagnostic hypothesis:

a) Fistulated prostate cancer.

25%

b) Acute diverticulitis, with bladder fistula.

25%

c) Sigmoid neoplasia, fistulized for bladder.

25%

d) Pyonephrosis.

25%

e) Perforated bladder neoplasia.

25%
   

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