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CASE REPORT |
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| Year : 2004 | Volume
: 20
| Issue : 2 | Page : 171-172 |
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Pyeloduodenal fistula - a case report
Nebu Issac Mammen
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
 Source of Support: None, Conflict of Interest: None  | Check |
Keywords: Fistula, renoalimentary.
How to cite this article:
Mammen NI. Pyeloduodenal fistula - a case report. Indian J Urol 2004;20:171-2 |
 Case Report | |  |
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 | | |
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 | | |
| 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.  |
| 2. | Bissada NK, Cole A, Fried FA. Renoalimentary fistula: an unusual urological problem. J Urol 1973; 1110: 273-6. |
| 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. |
[Figure - 1]
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