Entero-tubulo-uterine fistula in a patient with ulcerative colitis

Abstract

Ulcerative colitis (UC) is a type of inflammatory bowel disease that affects approximately 500,000 Americans. Although medical treatment is available for UC patients, surgery is often necessary and curative. Surgical treatment of fistulas is uncommon in UC compared to Crohn’s disease. In this paper, we report a case of a fistula complicating a total proctocolectomy with ileo-anal anastomosis in a patient with UC 5 years after the surgery. A 22-year-old woman with a history of UC and total colectomy with ileostomy in 2001 and ileostomy reversal in 2002 presented to the emergency department with a 1-day history of liquid, brown, foul-smelling feculent material discharging from her vagina. She denied any blood in the discharge and reported no history of prior episodes. She denied nausea, vomiting, fever, chills, or change in appetite or change in stooling habits. She reported moderate suprapubic fullness and bloating but denied rectal or vaginal pain. She has a history of irregular menses. The patient has a history of pelvic abscess formation as noted on prior admissions and computed tomographies. All of the abscesses responded quickly to antibiotics as an inpatient and outpatient. Her surgical history also includes a C-section in 2004. On review of symptoms, she reported weight loss and lower back pain radiating down bilateral legs for the last 8 months for which she has been taking methadone 5 mg twice daily to alleviate. Physical exam revealed a soft abdomen with mild suprapubic tenderness. There were no masses or distention, and bowel sounds were present. Rectal exam revealed perianal skin tags, normal rectal tone, normal healing of the anal anastomosis, and no masses. The patient deferred a pelvic exam at that time. A computed tomography was performed, which showed a pelvic abscess. The patient was admitted to the hospital for treatment of an enteropelvic fistula with pelvic abscess. A flexible sigmoidoscopy of the pouch was unremarkable and without any inflammation. Intravenous antibiotics were given with improvement of her symptoms. She was discharged. She was readmitted approximately 1 month later with recurrence of symptoms after failure of medical management with mesalmine and steroids. She was taken for endoscopy at which time a possible fistula opening was found. Next, she was taken for exam under anesthesia. This revealed feculent discharge from the cervix. The external opening seemed to end blindly near the anal anastomosis at the time of examination. The patients was worked up with small bowel follow through, which was normal. Because of recurrence of symptoms, another computed tomography was obtained, which showed worsening inflammatory change in the presacral tissue and a fistulous connection into the adjacent soft tissues of the adjacent bowel within the right hemipelvis. An abscess could not be ruled out by the radiologist. Pelvic magnetic resonance imaging was obtained without contrast. The uterus was found to be normal in appearance. Neither ovary was visualized. A 3.6×3-cm cystic lesion was visualized in the pelvis posterior to the uterus. A colonic barium enema was performed revealing an enterovaginal fistula tract projecting posterior from the J-pouch. Int J Colorectal Dis (2008) 23:449–450 DOI 10.1007/s00384-007-0381-0