Vesicoenteric fistula created by ingested foreign body in Meckel's diverticulum.

Abstract

A 40-year-old white male presented with recurrent episodes of dysuria associated with lower urinary tract infections, fever, hematuria with clots and abdominal pain. Abdominal ultrasound showed a small mass protruding from the posterior wall of the bladder, which demonstrated a gross calcification and an air bubble on the bladder dome. On direct questioning the patient described pneumaturia. Plain x-ray of kidneys, ureters and bladder confirmed the presence of a lumpy calcification measuring approximately 2 cm. in diameter in the mid pelvis (fig. 1). Excretory urography revealed calcification in a bladder filling defect. Magnetic resonance imaging (MRI) of the pelvis showed thickening of the posterior bladder wall in strict continuity with a bowel segment. Colonoscopy and multiple biopsies were normal. Cystoscopy demonstrated a 4 cm. mass protruding from the upper posterior wall of the bladder and marked edema of the overlying mucosa. During transurethral resection of the mass enteric material flowing from the area of resection revealed communication with the bowel, thereby making possible the diagnosis of vesicoenteric fistula. Histological examination showed granulomatous cystitis of the mucosa involving the lamina propria. Open laparotomy was performed and a limited tract of ileum was found fused to the upper posterior wall of the bladder. A limited ileal resection was performed, which included the portion of bladder wall intersected by the adhesion. An irregular cylindrically shaped foreign body 3 cm. in diameter was extracted from the bladder. During examination of the resected specimen it became apparent that the foreign body had initially been located in a Meckel’s diverticulum. The foreign body was identified as a chicken bone, which had inadvertently been ingested by the patient (fig. 2). The postoperative period was uneventful, and the patient was asymptomatic with sterile urine at 6-month followup. DISCUSSION