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CASE REPORT
Year : 2004  |  Volume : 20  |  Issue : 2  |  Page : 171-172
 

Pyeloduodenal fistula - a case report


Department of Urology, Pushpagiri Medical College Hospital, Tiruvalla, India

Correspondence Address:
Nebu Issac Mammen
Department of Urology, Pushpagiri Medical College Hospital, Tiruvalla - 689 101
India
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Source of Support: None, Conflict of Interest: None


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Keywords: Fistula, renoalimentary.


How to cite this article:
Mammen NI. Pyeloduodenal fistula - a case report. Indian J Urol 2004;20:171-2

How to cite this URL:
Mammen NI. Pyeloduodenal fistula - a case report. Indian J Urol [serial online] 2004 [cited 2019 Jun 18];20:171-2. Available from: http://www.indianjurol.com/text.asp?2004/20/2/171/20751



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A 58-year-old lady, a known diabetic, presented with a history of pain in the right flank of 2 weeks duration. Ul­trasound scan done earlier had shown right hydronephro­sis with a 1 cm calculus at the pelviureteric junction (PUJ). She also gave a history of recurrent fever with chills for one week.

Examination revealed an obese, febrile lady, in pain with a BP of 130/70 mm of Hg and a pulse rate of 90/min. The right hypochondrium was tender. Hemoglobin was 9.5 gm/dl. S.creatinine 1.7 mg% and urine microscopy showed 18-20 WBC/hpf.

Intravenous urogram showed a 1-1.2 cm sized calculus at the level of the 3 rd lumbar vertebra with marked delay in functioning of the right kidney. The right pelvicalyceal system was not visualized clearly.

A bulb ureterogram showed narrowing of the PUJ with free flow of the contrast outside the ureter into what looked like the small bowel. The stone, seen just above the nar­row area, moved into the pelvis. The contrast was also seen to go into the collecting system. Despite several at­tempts, the guide wire appeared to go only into the upper calyx and not into the pelvis. A double J-stent was passed over it.

The patient's pain and fever subsided the next day. However, the stent could not be seen in the collecting sys­tem on an ultrasound done for confirmation and there was a 3 cm collection seen outside the ureter. A computed tomography scan was done and it was found that the tip of the stent had moved into the duodenum with the duode­num being outlined by contrast even though only intrave­nous contrast had been given [Figure - 1].

The stent was removed the next day, a guide wire was passed into the pelvis under direct vision using a uretero­scope and a stent was passed into the pelvis. The postop­erative period was complicated by fever which settled only after ultrasound guided aspiration of thick pus from the 3 cm collection outside the ureter.

A month later, the stone was fragmented by ESWL and the stent was removed after another month. A bulb ureterogram done at the time of stent removal did not show any extravasation of contrast.


   Comments Top


Pyeloduodenal fistula is a known but unusual complica­tion. Several cases have been reported in the literature in the past. [1] These fistulae can be traumatic or spontaneous. Spontaneous fistulae can be secondary to inflammation or infection, stone and obstruction [2] or malignancy. [3] This case is a report of a case of pyeloduodenal fistula which occurred as a complication of a renal calculus. Treatment involves relief of obstruction by stenting or a percutaneous nephro­stomy. Once the obstruction is relieved, the fistula usually heals by itself if the condition is benign.

The patient discussed here is a diabetic and this may have predisposed to a silent perforation into the duode­num due to recurrent infection following obstruction by the stone. The authour would like to stress the impor­tance of early treatment of stones in diabetics and ob­structed systems and the success of endoscopic treatment in such cases.

 
   References Top

1.Desmond JM, Evans SE, Couch A, Morewood DJ. Pyeloduodenal fistulae. A report of two cases and review of literature. Clin Radiol 1989; 40: 267-70.  Back to cited text no. 1    
2.Bissada NK, Cole A, Fried FA. Renoalimentary fistula: an unusual urological problem. J Urol 1973; 1110: 273-6.   Back to cited text no. 2    
3.Chen CH, Cheng HL, Tong YC, Pan CC. Spontaneous pyeloduodenal fistula: an unusual presentation in advanced renal transitional cell carcinoma. Urology 2002; 60: 345.  Back to cited text no. 3    


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