Like a Rolling (Gall)Stone: Optimal Treatment of Gallstone Obstruction of the Sigmoid Colon.

BACKGROUND: Sigmoid gallstone ileus is a rare complication of cholelithiasis, accounting for 1-4% of all cases of large-bowel obstruction. This is a highly morbid, and often fatal, condition due to its challenging diagnosis and late presentation. CASE PRESENTATION: We report a case of a 90-year-old woman admitted to Emergency Department with abdominal pain and large-bowel obstruction due to a 6 cm gallstone lodged in a diverticulum of the proximal sigmoid colon as a consequence of a cholecysto-colonic fistula. Colonoscopy was deferred due to gallstone size carrying a high possibility of failure. The patient underwent urgent laparotomy with gallstone removal via colotomy. The cholecystocolonic fistula was left untreated. The post-operative course was uneventful; the patient was discharged on 6th post-operative day. CONCLUSION: A multidisciplinary discussion between endoscopists and surgeons is often needed to choose the best therapeutic option, especially in high-risk patients.

[Primary aortoduodenal fistula - a rare cause of life-threatening upper gastrointestinal bleeding]. / Primär aortoduodenal fistel.

Primary aortoduodenal fistula is a rare condition caused mainly by a bulging infra-renal aortic aneurysm with subsequent erosion of the duodenum and formation of a fistula. We present a patient who suffered from a herald upper gastrointestinal bleeding followed by circulo-respiratory collapse only hours after, due to bleeding from the fistula. The mortality is reported to be 100 %, requiring emergency EVAR or open aortic graft repair to control any further bleeding.

Diagnostic accuracy of abdominal contrast-enhanced multi-slice spiral CT after oral diluted iodide in a time segment for gastrointestinal fistula in patients with severe acute pancreatitis.

PURPOSE: To evaluate the diagnostic accuracy of abdominal contrast-enhanced multi-slice spiral CT after oral diluted iodide in a time segment (post-ODI ACE-MSCT) for gastrointestinal fistula (GIF) in severe acute pancreatitis (SAP). MATERIALS AND METHODS: Patients with SAP who underwent both post-ODI ACE-MSCT and endoscopy/surgery from 2017 to 2023 were continuously retrospectively involved. Their demographic information and clinical features were recorded prospectively in an in-hospital database. Using endoscopy/surgery results as the reference standard, the sensitivity, specificity, positive predictive value, negative predictive value, and accuracy of post-ODI ACE-MSCT for diagnosing GIF in SAP were calculated by a four-cell table. The consistency of the two diagnostic methods was evaluated by the Kappa test and McNemar's test. RESULTS: Using endoscopy/surgery as the reference standard, a total of 86 cases were divided into the GIF group (N = 52) and the non-GIF group (N = 34). Among the 52 cases of GIF, 88.5% (46/52) cases had a positive result and 11.5% (5/52) cases had a negative result of post-ODI ACE-MSCT for GIF. Among the 34 cases of non-GIF, 2.9% (1/34) case had a positive result and 97.1% (33/34) cases had a negative result of post-ODI ACE-MSCT for GIF. Post-ODI ACE-MSCT had a sensitivity of 88.5% (95% CI 75.9%-95.2%), a specificity of 97.1% (95% CI 82.9%-99.8%), a positive predictive value of 97.9% (95% CI 87.3%-99.9%), a negative predictive value of 84.6% (95% CI 68.8%-93.6%), and an accuracy of 91.9% (83.4%-96.4%). The kappa value was 0.834, and P < 0.001 by McNemar's test. There were no significant differences in diagnostic test characteristics between the two modalities. CONCLUSION: Post-ODI ACE-MSCT can diagnose GIF in SAP in a simple, noninvasive, and accurate way, and can provide earlier imaging evidence for clinical diagnosis and treatment.

Massive gastrointestinal bleed due to a primary aortoenteric fistula.

A man in his 60s attended emergency for acute-onset abdominal pain and haematemesis. Requiring resuscitation, a CT abdomen/pelvis revealed a primary aortoenteric fistula actively bleeding into the duodenum. His background included a previous severe Q-fever infection and a heavy smoking history. Despite attempts at resuscitation and an emergent surgical attempt at haemostasis, the patient did not survive the massive gastrointestinal haemorrhage.Even in less severe cases, management of aortoenteric fistulas is tricky. Blood cultures and angiographic imaging are important investigations in guiding surgical approach. The pathology tends to have a significant rate of mortality even at tertiary-level vascular surgical centres.

A Rare Case of Retroperitoneal Abscess Caused by Nephro-Colic Fistula Resulting from Staghorn Calculus.

BACKGROUND Nephro-colic fistulas are uncommon, generally caused by local inflammation, trauma, or neoplasia affecting the kidney or the colon. Their association with a coralliform stone is described in a few case reports, but their management is difficult and differs quite a lot, depending on the clinical situation. We report an atypical clinical case of a reno-colic fistula associated with a staghorn calculus. This case adds to the literature an iconography rarely found. CASE REPORT A 68-year-old woman presented to the Emergency Department with respiratory symptoms and chronic abdominal pain. The biological results showed a high inflammatory syndrome. The radiological assessment revealed a retroperitoneal and left retro-renal abscess, attributed to a left nephro-colic fistula associated with the partial passage of a lithiasis within the colonic lumen. Colonoscopy confirmed the diagnosis. Multiple recurrences of diverticulitis in this region could be the origin of the complication. First, the patient was treated with antibiotic therapy and radiological drainage. Second, she benefited from a left nephrectomy, left segmental colectomy, and splenectomy. The clinical and radiological evolution were favorable after surgery. The follow-up was disrupted by hospitalizations in the Cardiology Department for cardiac decompensation. CONCLUSIONS Kidney stones along with local inflammatory phenomena can be the cause of a nephro-colic fistula. Due to the lack of guidelines in such cases, their diagnosis and management are difficult to ascertain. Surgery is the right course of treatment.

Treating a Bypass with Bypass Surgery: Repair of a Duodeno-sigmoid Fistula Complicating Acute Diverticulitis.

Diverticular disease is common in Western countries; one-third of patients with diverticular disease develop diverticulitis during their lifetime of whom 5% may experience serious complications. We describe a rare complication of diverticulitis: a duodeno-colic fistula in a patient with an elongated sigmoid colon (dolicosigma). The patient complained of abdominal pain, diarrhea, weight loss, and feculent vomiting. Radiological studies and gastroscopy demonstrated a fistula between the second portion of the duodenum and the sigmoid colon. Curative surgery cured the fistula and completely resolved its associated signs and symptoms.

Endovascular Management of Aortic Stump Blowout by Parallel Grafting and Coil Embolization of Visceral Aorta.

Aortic graft and endograft infections remain a significant source of morbidity and mortality after abdominal aortic aneurysm repair. With graft excision and extra-anatomic bypass, an infrarenal aortic stump remains which can have suture line dehiscence and catastrophic stump blowout. Treatment of this is extremely challenging, especially for severely co-morbid patients who cannot undergo major surgery, or in patients with a hostile abdomen. We present a case study of a 74-year-old male found to have an aortoenteric fistula (AEF). This case broadens operative options for this type of patient population by demonstrating an endovascular technique for addressing aortic stump blowout by parallel grafting and coil embolization of the visceral aorta.

Diagnostic Accuracy of Intestinal Ultrasound in the Detection of Intra-Abdominal Complications in Crohn's Disease: A Systematic Review and Meta-Analysis.

BACKGROUND: Crohn's disease [CD] is frequently associated with the development of strictures and penetrating complications. Intestinal ultrasound [IUS] is a non-invasive imaging modality ideal for point-of-care assessment. In this systematic review and meta-analysis we provide a current overview on the diagnostic accuracy of IUS and its advanced modalities in the detection of intra-abdominal complications in CD compared to endoscopy, cross-sectional imaging, surgery, and pathology. METHOD: We conducted a literature search for studies describing the diagnostic accuracy of IUS in adult patients with CD-related intra-abdominal complications. Quality of the included studies was assessed with the QUADAS-2 tool. Meta-analysis was performed for both conventional IUS [B-mode] and oral contrast IUS [SICUS]. RESULTS: Of the 1498 studies we identified, 68 were included in this review and 23 studies [3863 patients] were used for the meta-analysis. Pooled sensitivities and specificities for strictures, inflammatory masses, and fistulas by B-mode IUS were 0.81 and 0.90, 0.87 [sensitivities] and 0.95, and 0.67 and 0.97 [specificities], respectively. Pooled overall log diagnostic odds ratios were 3.56, 3.97 and 3.84, respectively. Pooled sensitivity and specificity of SICUS were 0.94 and 0.95, 0.91 and 0.97 [sensitivities], and 0.90 and 0.94 [specificities], respectively. The pooled overall log diagnostic odds ratios of SICUS were 4.51, 5.46, and 4.80, respectively. CONCLUSION: IUS is accurate for the diagnosis of intra-abdominal complications in CD. As a non-invasive, point-of-care modality, IUS is recommended as the first-line imaging tool if there is a suspicion of CD-related intra-abdominal complications.

A Modern Series of Secondary Aortoenteric Fistula - A 19-Year Experience.

OBJECTIVES: Secondary aortoenteric fistula is a rare and life-threatening condition. Clear evidence on the ideal therapeutic approach is largely missing. This study aims to analyze symptoms, etiology, risk factors, and outcomes based on procedural details. PATIENTS AND METHODS: All patients with secondary aortoenteric fistula admitted between 2003 and 2021 were included. Patient characteristics, surgical procedure details, and postoperative outcomes were analyzed. Outcomes were stratified and compared according to the urgency of operation and the procedure performed. Descriptive statistics were used. The primary endpoint was in-hospital mortality. RESULTS: A total of twentytwo patients (68% male, median age 70 years) were identified. Main symptoms were gastrointestinal bleeding, pain, and fever. From the twentytwo patients ten patients required emergency surgery and ten urgent surgery. Emergency patients were older on average (74 vs 63 years, P = .015) and had a higher risk of postoperative respiratory complications (80% vs 10%, P = .005). Primary open surgery with direct replacement of the aorta or an extra-anatomic bypass with an additional direct suture or resection of the involved bowel was performed in sixteen patients. In four patients underwent endovascular bridging treatment with the definitive approach as a second step. Other two patients died without operation (1x refusal; 1x palliative cancer history). In-hospital mortality was 27%, respectively. Compared to patients undergoing urgent surgery, those treated emergently showed significantly higher in-hospital (50% vs 0%, P = .0033) mortalities. CONCLUSION: Despite rapid diagnosis and treatment, secondary aortoenteric fistula remains a life-threatening condition with 27% in-hospital mortality, significantly increased upon emergency presentation.

Utilization of point-of-care ultrasound to evaluate for enterovesical fistula.

Enterovesical fistula formation is a relatively rare disease process although a common complication for patients with inflammatory bowel disease (IBD), notably Crohn's disease. Enterovesical fistulas most commonly arise from diverticulitis (65-80%), cancer (10-20%), or Crohn's disease (5-7%). An increasing amount of evidence supports the use of ultrasonography as the primary imaging method for the monitoring of complications in individuals with a documented history of IBD. Our case report presents a 30-year-old female with a history of Crohn's disease who presented to the Emergency Department with concern for possible enterovesical fistula formation. Using bedside gray-scale ultrasonography, a fistulous tract clearly visualizing air bubbles and fecal matter actively moving from bowel to the bladder through the fistula was visualized confirming the diagnosis of an enterovesical fistula. While CT imaging is instrumental in identifying mural and extramural complications of IBD, performing ultrasonography in patients with IBD serves as an efficient, inexpensive, and noninvasive diagnostic aid for the diagnosis of enterovesical fistula.

Revascularization and Digestive Tract Repair in Secondary Aortoenteric Fistula Using a Single-Center in Situ Revascularization Strategy.

BACKGROUND: Information regarding optimal revascularization and digestive tract repair in secondary aortoenteric fistula (sAEF) remains unclear. Thus, reporting treatment outcomes and presenting comprehensive patient details through a structured treatment approach are necessary to establish a treatment strategy for this rare, complex, and fatal condition. METHODS: We performed a single-center retrospective review of consecutive sAEF managed based on our in situ revascularization and intestinal repair strategy. The primary endpoint of this study was all-cause mortality, and secondary endpoints were the incidence of in-hospital complications and midterm reinfections. RESULTS: Between 2007 and 2020, 16 patients with sAEF, including 13 men (81%), underwent in situ revascularization and digestive tract repair. The median follow-up duration for all participants was 36 (interquartile range, 6-62) months. Among the participants, 81% (n = 13), 13% (n = 2), and 6% (n = 1) underwent aortic reconstruction with rifampin-soaked grafts, unsoaked Dacron grafts, and femoral veins, respectively. The duodenum was the most commonly involved site in enteric pathology (88%; n = 14), and 57% (n = 8) of duodenal breaks were repaired by a simple closure. Duodenum's second part-jejunum anastomosis was performed in 43% of patients (n = 6), and 19% of the patients (n = 3) died perioperatively. In-hospital complications occurred in 88% patients (n = 14), and the most frequent complication was gastrointestinal. Finally, 81% patients (n = 13) were discharged home. Oral antibiotics were administered for a median duration of 5.7 months postoperatively; subsequently, the participants were followed up carefully. Reinfection was detected in 6% of the patients (n = 1) who underwent reoperation without any complications. The 1-year and 3-year overall survival rates of participants were 75% (n = 12) and 75% (n = 9), respectively, and no sAEF-related deaths occurred, except perioperative death. CONCLUSIONS: Surgical intervention with contemporary management based on our vascular strategy and digestive tract procedure may be a durable treatment for sAEF.

Enterovesical Fistula in a Lymphoma Patient Revealed by FDG PET/CT With an Oral Contrast Agents.

ABSTRACT: A 60-year-old man with colonic diffuse large B-cell lymphoma was referred for FDG PET/CT for initial staging. He was suspected of enterovesical fistula. After oral administration, large amounts of contrast agents accumulated in the bowel lumen and leaked into the bladder through a well-marked fistulous tract. Corresponding to the fistula, a linear pattern of FDG uptake extended from the bladder into the colonic lumen, and the measured SUV max inside the lesion was as high as that of the urinary bladder. Cystography confirmed the presence of the enterovesical fistula.

Ileal conduit to small intestine fistula following extensive abdominopelvic resection and radiation for metastatic colon cancer.

A woman in her mid-60s presented with decreased output from urostomy, which was an opening from the neobladder (ileal conduit). Presentation was preceded by a 6-month history of alternating faecaluria and increased colostomy output. Laboratory studies were notable for normal anion gap metabolic acidosis. Creatinine level of the colostomy output was 17.7 mg/dL, a finding indicative of the presence of urine in the sample. CT enterography and X-ray loopogram confirmed neobladder to small intestine fistula.Neobladder creation is commonly performed in patients with bladder cancer requiring resection. Fistulas between the neobladder and intestine are observed in fewer than 2.7% of cases. The patient's history of extensive abdominopelvic resection, colostomy creation and radiation likely contributed to fistula development. We highlight the need for a high index of suspicion for a fistula in a patient with a neobladder experiencing recurrent urinary tract infections or a high colostomy output concurrently with low neobladder output.

Iatrogenic enterovesical fistula secondary to a permanent urinary catheter.

An enterovesical fistula is a rare entity resulting from inflammatory, neoplastic and iatrogenic processes. It can manifest clinically as pneumaturia and recurrent urinary tract infections. Its diagnosis is supported by imaging examinations and its treatment is primarily surgical.

Emergent Endovascular Repair For Primary Aortoenteric Fistula.

We report the case of a 64-year-old male with significant cardiac comorbidities who reported three episodes of gastrointestinal bleeding. In the third episode, he presented massive hematemesis, anaemia and hypotension. Despite a standard upper endoscopy, a computed tomography (CT) showed an infrarenal abdominal aortic aneurysm and densification of the aortic fat cover. A primary aortoenteric fistula, with acute bleeding and haemodynamic instability, was assumed, and an emergent endovascular repair was performed. Subsequent CT scans and endoscopies demonstrated control of the enteric lesion. After five months, there was no evidence of infection or rebleeding.

Unique case of colovesical fistula in a renal allograft recipient.

Colovesical fistula is commonly suspected in cases of diverticular disease, malignancy, trauma, iatrogenic injury or radiotherapy. In a case of allogenic live related transplant, this is rarely expected, especially after 20 years. The presence of gas in the bladder in the absence of history of instrumentation of urinary tract should prompt us to evaluate for colovesical fistula. Pneumaturia, faecaluria and recurrent urinary tract infection are tell-tale features of colovesical fistula, and when patients who are renal allograft recipient present with them, it should prompt a proper workup and swift surgical management, since the outcome is uniformly favourable. From our knowledge in this realm, we know that these are immunocompromised patients and have a high tendency to develop risk factors like malignancy and/or diverticular disease and eventually form colovesical fistula. An expected time period could be from 2 months to 6 years. But in our case, fistula formation occurred long after peak corticosteroid action, in the absence of conventional aetiologies.