Ileo-ureteric with Ileo-uterine fistula
A 62 year old female† presented in the department of Surgical Gastroenterology, All India Institute of Medical Sciences, Jodhpur, India in February 2018, with complaints of feculent discharge per vagina and pneumaturia since one month. She had no history of tuberculosis (TB) and was taking analgesics with steroids for polyarthropathy. Computed tomography reported a thick walled loculated collection (~5.5 x 3.5cm) in right adnexal region communicating with the uterus and ileum (Fig. 1A). Right distal ureter was communicating with this collection with moderate hydroureteronephrosis (Fig. 1B-D). There were no features of TB seen on imaging.
Percutaneous nephrostomy was performed to drain the infected right kidney. Exploratory laparotomy revealed adherent terminal ileum to the uterus (Fig. 2A). After dismantling, stricture with perforation was noted in ileum, which was resected and ileo-ascending anastomosis was done. Hysterectomy with bilateral salpingo-oophorectomy was performed and boari flap of urinary bladder was created to anastomose with ureter (Fig. 2B-D). Histopathology (HP) of ileum suggested non-specific chronic ileitis and typhilitis with reactive lymphoid proliferation. HP of uterus and resected ureter also revealed chronic inflammation with no evidence of TB or malignancy.
To summarise, a silent ileal perforation secondary to chronic use of analgesic and steroids led to a pelvic abscess that eroded into the ureter and uterus leading to a complex fistula.
† Patient's consent obtained to publish clinical information and images.© 2021 Indian Journal of Medical Research | Published by Wolters Kluwer – Medknow