Diagnosis and Management of Enterovesical Fistulas in Patients with Crohn's Disease

Abstract

The objective of this study was to investigate the clinical manifestations and diagnostic studies used to evaluate Crohn's patients with enterovesical fistulas (EVFs) and to assess outcome after surgical intervention. This is a ten year multi-institutional retrospective chart review of patients with Crohn's disease. Of 400 patients identified with Crohn's disease eight (2%) were diagnosed with EVF. The mean age at diagnosis was 27 years. No patients had prior surgeries for Crohn's. Duration of symptoms ranged from 6 months to 15 years. There were seven ileovesical and one colovesical fistula identified. One patient had associated perianal disease. Three had concomitant enteroenteral fistulae. Clinical features included pneumaturia in seven patients (88%), fecaluria in three (38%), hematuria in five (63%), and urinary tract infection symptoms in seven (88%). Diagnostic studies included CT scan in six, barium or gastrografin enema in four, and cystoscopy in four. Surgical therapy involved resection of the affected bowel. The bladder defect was closed primarily in two layers in all patients using absorbable suture, with omental patch in four. Two patients underwent ileostomy and one underwent colostomy, all taken down within 6 months. There were no bladder leaks and no anastamotic leaks. There were no perioperative deaths. The mean postoperative stay was nine days. The mean follow-up was 39 months. We conclude that pneumaturia is a strong clinical indicator of EVF. CT has been valuable in identifying gas within the bladder in these patients. Cystoscopy has proven useful in identifying the fistulous tract and in evaluation of the ureters. The presence of an EVF should heighten suspicion as to the presence of concomitant enteroenteral fistulae. Barium or gastrografin studies are useful in this capacity. Surgical treatment of EVFs should include resection of affected bowel. The bladder defect can safely be closed using absorbable suture.

Colovesical fistula in men with chronic urinary tract infection: A diagnostic challenge

“…The risk of developing a colovesical fi stula in patients with diverticular disease is 1% to 4%. 2,3,6,8 The mechanism is thought to be direct extension of a ruptured diverticulum or erosion of a peridiverticular abscess into the bladder. Peridi-verticular phlegmon and abscesses are risk factors for future fi stula formation.…”

“…1,4,5 Regional enteritis with transmural infl ammation may result in adhesion of the infl amed section of the bowel to the bladder, followed by erosion with fi stulization. 1,4,5,6,10 Iatrogenic surgical injury is an uncommon cause of colovesical fi stula but may be increasing in absolute numbers as more men undergo surgery in this part of the body. Colorectal, diverticular, and urologic surgery are some of the more common procedures associated with colovesical fi stula.…”

“…1 Frequency, urgency, and suprapubic pain are present in almost all cases but are indistinguishable from symptoms of regular urinary tract infection. 1,6 ■…”

“…1 All of these factors contribute to delayed diagnosis and prolonged suffering. [4][5][6] Here, we review the etiology, clinical presentation, diagnosis, and management of colonic fi stula and propose a diagnostic approach.…”

Renal and Urological Disorders Associated With Inflammatory Bowel Disease

“…Presenting clinical features may be pneumaturia, urinary tract infection, and fecaluria-or a combination thereof. 34,35 Comprehensive evaluation of suspected entero-vesical fistula typically requires the utilization of several imaging modalities to precisely define the fistulous connection, the presence of an abscess, and the exclusion of coexistent bowel stricturing. Historically, plain abdominal x-ray, barium enema, and intravenous urography were used, but these have been superseded by cross-sectional imaging.…”