Correspondence

Vesicoileal Fistula in a Patient with Hematochezia and Hematuria

N Engl J Med 2003; 348:1820-1821May 1, 2003

Article

To the Editor:

Vesicoenteric fistula usually develops as a complication of colonic diverticulitis, although other conditions, such as colorectal cancer, Crohn's disease, and bladder cancer, may be associated with it. Urinary symptoms such as pneumaturia and dysuria are the most common symptoms. We describe the development of vesicoileal fistula as a complication of postoperative radiation therapy for cervical cancer.

A 45-year-old woman visited the emergency department with hematochezia and gross hematuria that had begun simultaneously. The initial vital signs were relatively stable, with a blood pressure of 133/83 mm Hg, a heart rate of 86 beats per minute, and a temperature of 36.6°C. There were no specific findings on physical examination, except for dark blood on rectal examination. The hemoglobin level was 6.8 g per deciliter (hematocrit, 22.1 percent). Urinalysis showed many red cells. There were no abnormalities in the bleeding profiles. Two years before admission, the patient had undergone laparoscopy-assisted radical hysterectomy with pelvic lymph-node dissection for cervical cancer (poorly differentiated, intestinal-type adenocarcinoma, stage IB) and postoperative radiation therapy at 50.4 Gy. She had received repeated radiation therapy at 36 Gy until six months before admission. On colonoscopic examination, no definite origin of bleeding or mucosal abnormalities in the colon were found, although some fresh blood remained. Full inspection of the stomach, duodenum, and small bowel showed no abnormality. Hematochezia and gross hematuria stopped three days after admission without any interventions.

Cystography was performed to check the status of the bladder. Surprisingly, contrast dye that was infused into the bladder appeared in the terminal ileum and colon (Figure 1Figure 1Cystographic Images.). On cystoscopy, no patulous opening of the fistula could be found in the bladder, but a punctate lesion with mucosal erythema was found on the posterior wall and was thought to be the opening of the fistula tract.

Vesicoileal fistula is a very rare condition. We could find only a few cases in the literature.1-5 Each patient had important diseases in either the bladder or the ileum, including bladder cancer,1 Crohn's disease,2 Meckel's diverticulum,3 a post–ureteroileoneocystostomy-undiversion state,4 and malignant lymphoma of the ileum.5 Although vesicoenteric fistulas require surgical treatment, the fistula in our patient was thought to have disappeared within several days. The patient remains healthy, without urinary or enteric symptoms. Physicians should keep in mind the possibility that vesicoileal fistula can be the origin of hematochezia and hematuria in patients with a history of pelvic surgery or irradiation.

Myoung-Kuk Jang, M.D., M.S.
Sung-Koo Lee, M.D., Ph.D.
Seung-Jae Myung, M.D., Ph.D.
Asan Medical Center, Seoul 138-736, Republic of Korea
mkjang2@yahoo.com

5 References

1. 1

   Finkelstein LH, Arsht DB, Trenkle D. Vesicoileal fistula: an unusual complication following the use of formalin for control of refractory post-irradiation bladder hemorrhage. J Urol 1977;117:168-170
   Web of Science | Medline

2. 2

   Suzuki H, Yamanishi T, Isaka S, Yasuda K, Shimazaki J, Sarashina H. Vesicoenteric fistula complicating Crohn's disease, responded to medical treatment: a case report. Hinyokika Kiyo 1992;38:337-341
   Medline

3. 3

   MacKenzie TM, Kisner CD, Murray J. Vesicoileal fistula via Meckel diverticulum. Urology 1989;33:475-476
   CrossRef | Web of Science | Medline

4. 4

   Klein FA, Broecker BH, Koontz WW Jr, Texter JH Jr. Spontaneous vesicoileal fistula two years post ureteroileoneocystostomy undiversion. Urology 1985;26:393-395
   CrossRef | Web of Science | Medline

5. 5

   Kang JG, Hwang CI. Vesicoileal fistula caused by malignant lymphoma: a case report. Korean J Urol 1984;25:387-392