A Case of Duodenoureteral Fistula Formation

Abstract

Duodenoureteral fistulas are rare occurrences. They are most often seen with trauma, ingestion of foreign body, chronic renal infections, duodenal ulcer disease, or ureteral calculi. This is the case of a 63-year-old male with a history of polysubstance abuse, COPD and heart failure with reduced ejection fraction and diastolic dysfunction admitted to the hospital with a nine day history of right sided abdominal pain. The patient denied any fevers, chills, nausea, vomiting, changes in bowel habits, dysuria, or hematuria associated with the pain. CT imaging on admission demonstrated mild-moderate right hydronephrosis with abrupt narrowing of the right proximal ureter, irregularities in the duodenal lumen suspicious for duodenitis, and pericholecystic fluid (Figure 1). Follow-up right upper quadrant ultrasound demonstrated no gallbladder or liver abnormalities. Blood cultures and urinalysis were done and empiric ceftriaxone and metronidazole were started. A retrograde urogram identified a fistula between the right ureter and duodenum with extravasation of dye into the small bowel (Figure 2). A right ureteral stent was placed. Initial blood cultures and HIV testing returned negative. With continued fevers to 103, repeat blood cultures were drawn and the patient's antibiotics were then broadened to Zosyn. EGD performed the following day demonstrated a toothpick penetrating the wall of the descending duodenum (Figure 3). The toothpick was removed via forceps and clips were applied to close the fistula. Blood cultures drawn at the time of the fever spike grew Candida krusei, attributed to a GI source with translocation of the organism to the blood stream via the toothpick. The patient improved following a 21-day course of micafungin. This case is an instance of foreign body ingestion resulting in penetration of the duodenum with formation of a duodenoureteral fistula. Course was complicated by hydronephrosis and Candida krusei bloodstream infection. Candida krusei septicemia is rare in immunocompetent patients and should prompt a search for an etiology.1894_A Figure 1. CT Abdomen1894_B Figure 2. Retrograde Urogram1894_C Figure 3. Endoscopic View of Foreign Body