Overview
This lecture discusses a rare case of spontaneous colo-vesical and colo-cutaneous fistula complicating sigmoid diverticulitis, its diagnosis, management, and relevant clinical considerations.
Diverticular Disease and Fistula Formation
- Diverticular disease commonly affects older adults, especially in Western countries.
- Complications of diverticulosis include diverticulitis, obstruction, abscess, hemorrhage, and fistula.
- Fistulas arising from diverticulitis occur in about 2-4% of complicated cases.
- The Hinchey and Hensen-Stock classifications are used to stage diverticular disease; fistula is group IIb in Hensen-Stock.
- Colo-vesical fistulas are the most frequent type, while colo-cutaneous fistulas are rare (1-4% of all diverticular fistulas).
- Concurrent spontaneous colo-vesical and colo-cutaneous fistula are extremely rare, especially without prior intervention.
Case Presentation
- A 68-year-old male with a history of sigmoid diverticular disease and prior hernia surgeries presented with fecal fistula and recurrent urinary tract infections.
- Symptoms included fecaluria and a visible fistula in the left inguinal area.
- CT scan revealed air in the bladder and a fistula tract from the sigmoid colon to the abdominal wall.
- Initial surgery was an end-colostomy to manage infection; planned future procedure is laparoscopic colectomy.
- Patient's post-operative recovery showed good quality of life.
Diagnosis and Management
- Diagnosis relies on clinical symptoms (fecaluria, pneumaturia, recurrent UTIs) and imaging (CT scan confirms fistula and air in bladder).
- Colonoscopy may be used to exclude malignancy.
- Laparoscopic sigmoid resection is safe, effective, and reduces post-op complications.
- Open surgery and staged approaches may be necessary in patients with acute comorbidities (e.g., renal failure).
- There are no standard guidelines; management must be individualized.
Surgical Treatment Controversies
- Surgical treatments include end-colostomy, resection of the affected colon segment, fistula tract excision, and bladder repair.
- Techniques for bladder closure vary from simple closure to partial cystectomy, depending on extent.
- The surgical approach should avoid recent infection or abscess sites.
Key Terms & Definitions
- Diverticulitis — Inflammation or infection of diverticula in the colon.
- Fistula — An abnormal connection between two body parts.
- Colo-vesical fistula — Abnormal tract between the colon and bladder.
- Colo-cutaneous fistula — Abnormal tract between the colon and skin.
- Fecaluria — Presence of fecal matter in urine.
- End-colostomy — Surgical creation of a stoma at the colon’s end for fecal diversion.
Action Items / Next Steps
- Review diverticular disease classifications and complications.
- Understand imaging findings and symptomatology of fistulas.
- Read about laparoscopic and open surgical management strategies.
- Explore recent studies or systematic reviews on diverticular fistula treatments.