Enterovesical Fistula in an Elderly Crohn's Disease Patient

Abstract

A 79-year-old man presented to our department with a 2-week history of urinary urgency and fever. His medical history was notable for multiple ileal ulcers that were diagnosed by colonoscopy 1 year ago; aspirin was considered as the cause and then was stopped. Laboratory studies included a white blood cell count of 33,000/mm 3 and urine white blood cell count of 11,292/mL. Meropenem, piperacillin/tazobactam, linezolid, and levofloxacin were administered according to a drug sensitivity test. Magnetic resonance urography showed an enterovesical fistula (Figure A, arrow) and air in the bladder (Figure B, arrow), which was confirmed by cystoscopy. Repair of the enterovesical fistula with ileocecal resection was performed. Pathology showed longitudinal fissuring ulcers extending to the serosa (Supplementary Figure A), suggestive of Crohn's disease. One year later, the patient developed another enterovesical fistula (Supplementary Figure B). Enterovesical fistulas are rare but serious complications of Crohn's disease. Pneumaturia and recurrent urinary tract infections are the most common symptoms. Enterovesical fistulas are difficult to treat and recurrence is common.

Characteristics of Enterovesical Fistula Patients Visiting the Urology Department of Dr. Hasan Sadikin General Hospital Bandung, Indonesia, from 2015 to 2019

“…The relative risk for developing EVF in the presence of diverticular disease is between 1 and 4%. 3,4 The underlying mechanism is a direct extension of ruptured diverticulum or erosion of a peri diverticular abscess into the bladder, and a phlegmon and abscess are the risk factors for subsequent fistula formation. The second most common cause of EVF is cancer (10-20% of cases), followed by Crohn's disease (5-7%).…”

“…While only approximately 2% of patients with Crohn's disease develop EVF, ileovesical fistula remains the most common type. 1,4 The earliest and most common symptom is irritation of the urinary tract, which is recurrent and difficult to cure. Pathognomonic features of pneumaturia and faecaluria appear later.…”