Parietal entero-uterine fistula

Abstract

A c.4sE of parietaI entero-uterine fistuIa is reported, the first such case treated in the Robert Packer HospitaI. A review of the Iiterature indicates that seventy-three cases of entero-uterine fistuIa have been reported. In 1933 Danforth and Case’ recorded a case of entero-uterine fistuIa which was of carcinomatous origin. UntiI then onIy fifty-eight cases of simiIar IistuIas had been reported, most of these by Le Jemte12 and Neugebaur.3 In rg3g Dwyer4 recorded his case of sigmoido-uterine IistuIa and thirteen additiona1 cases. Dnyer’s case occurred foIIowing spontaneous rupture of a gravid uterus, with the feeta skuI1 bones perforating into the Iumen of the intestine. The patient recovered foIIowing extensive surgery which included preIiminary emptying of the uterus, supracervica1 hysterectomy, resection of the iIeum and cIosure of the opening in the sigmoid coIon. In 1943 Rose” reported stiI1 another case, which occurred in a young woman deIivered of a stiIIborn child; subsequently the woman was proved by surgery to have a fistula between the smaI1 intestine and one horn of a uterus bicornis. In this case Rose believes that the IistuIa resuIted from an attempt to end the pregnancy. Rose’s case is the selrenty-third case recorded in the Iiterature. RecentIy, another case of entero-uterine fistula was reported by Johnston and Stubbs.6 This last case was the resuIt of ruptured rliverticuIitis. The case presented herein is the seventy-fifth case of enter-o-uterine fistuIa. However, none of the previousIy recorded cases mentioned any other invoIvement besides intestina1 and uterine components to the fistuIa. Our case appears to be the only one invoIving a third component, that of the anterior abdomina1 wall; hence the name parieta1 entero-uterine IistuIa. Le Jemtel’ cIassifies entero-uterine hstuIas etioIogicaIIy as foIIows: (I) Cancer: by infiltration and invasion by a malignancy arising either in the bow4 or uterus and invading the other structure with subsequent communication of the lumens. (2) Peritonitis: pathologic puerperium, and appendicuIar. This follows infection with abscess formation involving the inflamed waIIs of the uterus and intestine, resuIting in subsequent communication. Under this classification shouId be added the IistuIa arising secondary to ruptured diverticulitis. This was the mechanism of Noecker’s7 case reported in rgzg and Johnston and Stubbs”j case recorded in 1955. (3) Ruptures of the uterus either spontaneous or produced during Iabor. A Ioop of bowel is thus entrapped within the uterine tear, following which strangulation of the boll-e1 results when the uterus contracts. Gangrene resuIts and the intestina1 contents escape by way of the genital cavity. In the series of fifty-eight cases recorded I>!: Le JemteI,2 thirty-seven foIIowed injury, fourteen after infIammatory processes and only seven cases after carcinoma. With the better management of obstetric complications and inflammatory abdomina1 disease, it would be reasonable to expect that most of these hstulas (if not all) wil1 arise secondary to ahdomina1 carcinoma. The Iocation of the IistuIous tracts is usually between the fundus of the uterus or point of injury to the uterine waI1, and the smaI1 intestine, sigmoid, rectum, cecum or even the stomach. At times the exact site of the intestina rent cannot be demonstrated except by x-ray or at surgery. Diagnosis is essentia1 so that proper therapy may be instituted. The cIinica1 history of profuse uterovagina1 discharge which may be feca1 in character or contain undigested food is the “tip-off.” Examination wiI1 revea1 that the discharge emanates from the uterus and not via a vagina1 component of a rectovagimd hstuIa. Past history of intra-abdominal inflammatory disease (appendicitis or diverticuIitisj, or operative or obstetric trauma is helpful