Acute diverticulitis complicated by fistula formation
- John H Pemberton, MD
John H Pemberton, MD
- Professor of Surgery
- Mayo Clinic and Mayo Medical School
Fistula formation is one of the complications of diverticulitis, accounting for up to 20 percent of surgically treated cases of diverticular disease . Diverticulitis in western countries usually involves the sigmoid colon, and fistulization most frequently arises from this segment. The major types of fistulas are colovesical fistulas (65 percent, (image 1)) and colovaginal fistulas (25 percent), followed by coloenteric and colouterine fistulas . However, a fistula can form to whichever organ the inflammatory process tracks, and has been described in many unexpected sites (image 2) .
Diverticulitis is also the most common cause of a colovesical fistula, accounting for 40 to 90 percent of cases . Although diverticulitis occurs with a slight female predominance, colovesical fistulas secondary to diverticulitis has a distinct (2 to 3:1) male predominance [1,4]. It is likely that the uterus protects the bladder from the inflamed sigmoid; this hypothesis is supported by the observation that the majority of women with colovesical or colovaginal fistulas have had a previous hysterectomy [1,3,5].
Colovesical fistulas illustrate the features of most diverticular fistulas. Only about one-half of patients have a history of diverticulitis; in the remainder, diverticulosis is diagnosed when the fistula becomes clinically evident . Affected patients often give a history of passage of stool and gas via the involved organ. Thus, common symptoms with a colovesical fistula include pneumaturia, dysuria, or irritative symptoms, and fecaluria [1,3,4]. Other symptoms occurring in fewer than 50 percent of patients are crampy abdominal pain, diarrhea, hematuria, and passage of urine per rectum [1,4].
Physical examination is frequently unremarkable. The urinalysis is invariably abnormal and cultures reveal the nonspecific finding of polymicrobial growth.
These findings occurring together are suggestive of a colovesical fistula, but not of the etiology. Causes other than diverticulitis include Crohn's colitis and carcinoma.
- Woods RJ, Lavery IC, Fazio VW, et al. Internal fistulas in diverticular disease. Dis Colon Rectum 1988; 31:591.
- LaSpina M, Facklis K, Posalski I, Fleshner P. Coloseminal vesicle fistula: report of a case and review of the literature. Dis Colon Rectum 2006; 49:1791.
- Mileski WJ, Joehl RJ, Rege RV, Nahrwold DL. One-stage resection and anastomosis in the management of colovesical fistula. Am J Surg 1987; 153:75.
- Jarrett TW, Vaughan ED Jr. Accuracy of computerized tomography in the diagnosis of colovesical fistula secondary to diverticular disease. J Urol 1995; 153:44.
- Miller RE. Role of hysterectomy in predisposing the patient to sigmoidovesical fistula complicating diverticulitis. Am J Surg 1984; 147:660.
- Labs JD, Sarr MG, Fishman EK, et al. Complications of acute diverticulitis of the colon: improved early diagnosis with computerized tomography. Am J Surg 1988; 155:331.
- Birnbaum BA, Balthazar EJ. CT of appendicitis and diverticulitis. Radiol Clin North Am 1994; 32:885.
- Laurent SR, Detroz B, Detry O, et al. Laparoscopic sigmoidectomy for fistulized diverticulitis. Dis Colon Rectum 2005; 48:148.
- Bartus CM, Lipof T, Sarwar CM, et al. Colovesical fistula: not a contraindication to elective laparoscopic colectomy. Dis Colon Rectum 2005; 48:233.
- Pokala N, Delaney CP, Brady KM, Senagore AJ. Elective laparoscopic surgery for benign internal enteric fistulas: a review of 43 cases. Surg Endosc 2005; 19:222.
- Rothenberger DA, Wiltz O. Surgery for complicated diverticulitis. Surg Clin North Am 1993; 73:975.
- Amin M, Nallinger R, Polk HC Jr. Conservative treatment of selected patients with colovesical fistula due to diverticulitis. Surg Gynecol Obstet 1984; 159:442.