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Colovesical fistula - Ärzteforum

Post#1 »

I was asked to see a 76 y.o. female yesterday with pneumaturia. She has had it about a month and been treated by her FP with antibiotics for a UTI. She had a TAH, BSO and bladder suspension about 4 years ago. She also carries the DX of Crohn's colitis for about 5 years. Colonoscopy in 2014 showed only sigmoid irritation and a stricture from 30 to 40 cm. A colonoscopy this fall showed a dense stricutre that could not be traversed but on biopsy looked like Crohn's. She has been on steroids (10 to 40 mg of Prednisone) since November for what sounds like obstructive symptons. She has no fever, is well nourished, a non smoker, WBC 6,000. PE she is tender in the LLQ with the impression of a mass but CT shows a thickened sigmoid colon with no abcess.

I have her scheduled for surgery tomorrow. In the face of steroids and presumed Crohn's colitis, would anyone resect and perform an anastamosis? Would anyone vote for a Hartman?


Re: Colovesical fistula - Ärzteforum

Post#2 »

If this lady has Crohn's my name is John Smith.

A few months a go I had a similar, albeit much younger patient, with a sigmoid stricture and history of pneumaturia -labaled and treated as Crohn's -for many painful years. At operation he had a diverticular mass. Your patient probably is suffering from sigmoid diverticultlis. What is the rush to operate her?

Wean her off the steroids and then operate (she is not obstructed-is she?).

To continue on my favorite topic- too many gastroenterologists who diagnose too much Crohn's which allows them too many "follow-up" endoscopies and office visits to "adjust" the medical treatment- poisoning the patients with unnecessary steroids.

Primary anastomosis "with" steroids" adds a little to the leakage rate. I would go ahead with anastomosis however -provided her nutrition is adequate.

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Re: Colovesical fistula - Ärzteforum

Post#3 »

A difficult case no matter what you do--obviously appears to be a colovesical fistula, requiring simple excision--actually more likely to be from diverticulitis than Crohn's but either is possible. I would resect and anastomose--give Vitamin A perioperatively to counteract the wound-healing detriment of steroids. Just recognize, along with the patient , the high risk--you are not solving much by doing colostomy--what do tyou think of this patient's chances of coming thru another operation without complication when you close the colostomy? What is the benefit of subjecting her to two rather than one operation? she will still have Crohn's disease and be on steroids when you bring her back to close the ostomy, so what are you accomplishing? Obviously your abdominal fascia is also at higher than normal risk of dehiscence--would that keep you from closing the fascia, and just packing open to come back another day? Think about it--there is really no reason to avoid an anastomosis, as it will not really increase the risks over any other approach--rather, do the right thing, and do your best to minimize risks, including trying to keep operating time, and number of procedures, to a minimum.

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Re: Colovesical fistula - Ärzteforum

Post#4 »

Unless a lot of pus go for primary anastamosis.

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Re: Colovesical fistula - Ärzteforum

Post#5 »

Please send me the protocol for the talc. You have my vote for the Hartman.

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Re: Colovesical fistula - Ärzteforum

Post#6 »

Did the patient have a SBFT to look at the small bowel before. Assuming her alb > 3.0 I would resect and perform an anastomosis. Simple closure of the bladder with indwelling foley for 7 days. You may want to do a cystogram before removing the foley. Cont steroid and adding 5-ASA has shown to decrease recurrence although not as much in large bowel CD.


Re: Colovesical fistula - Ärzteforum

Post#7 »

Yesterday I came back home at 10 PM because I had to reopen a patient with Crohn's ileitis operated 5 days ago (right colectomy and suture of a ileosigmoid fistula). She was been on corticosteroids and cyclosporine as well. No fever, mild abdominal tenderness, just a lot of enteroid fluid from both the abdominal drainages. I found heavy fecal peritonitis, 3-4 liters of enteric fluid in her abdomen and a COMPLETE leaking both of ileotrasversostomy and colonic suture. I had to resect the right transverse colon, definitive ileostomy, proximal colostomy and resection on the sigma without reconstruction (something like Hartmann). Those tissues looked as never tried to start healing.

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Re: Colovesical fistula - Ärzteforum

Post#8 »

On the contrary, further comments are very necessary--your point is clearly that anastomosis should not be performed in Crohn's colitis? What hogwash! Are you really trying to advance this concept simply on the basis of your one anecdotal case, as opposed to a wealth of evidence to the contrary? We really have to get beuyond this very adolescent view of science (or actuyally, the lack thereof) and we should know better on this net the fallacies of basing therapeutic decisions on anecdote. Have you never had an anastomotic leak following, say, colon resection for tumor? Does this mean we now shouldn't do primary anastomosis for colon tumors too? Yes--by your logic!


Re: Colovesical fistula - Ärzteforum

Post#9 »

I have a couple of the same. Ten days ago I was asked to do a loop-ileostomy for a patient with Crohns disease of the sigmoid. He had been treated with steroids and 5-ASA plus azathioprine with little clinical benefit. And he became tired and incontinet with all "diarrhea". The patient is 76 years, a somewhat unusual age for debut of Crohn's. The diagnosis was based on endoscopy only. Ulcerations of the sigmoid. A CT showed thickened sigmoid.

Looking around with the laparoscope I saw a typical chronic sigmoiditis. I did the ostomy and had a talk with the GI people suggesting a reassessment of the diagnosis. The first diagnosis at this age and this site of the bowel is sigmoiditis until proven otherwise.

He is to be taken off all medication and then operated. I am pretty certain about the diagnosis.

This was not the first such case in my experience. Some years ago I did a colectomy in a ICU-sick old lady thought to have ulcerative colitis. But it was sigmoiditis. It almost foooled me until I cut open the excised colon and found no colitis.

I suppose the message is to be aware of that sigmoiditis/diverticulitis is not a medical disease and hence not considered by gi people. Inflammatory bowel disease is what gastroenterologists first have in mind. Like we have cancer.

Also, don't have the gastroenterologist rush you into operations. If there is not time to think they are too late about the consultation. Surgeons should not be asked to do emergency operations for IBD. There is always time if the gastroenterologist is good.

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Re: Colovesical fistula - Ärzteforum

Post#10 »

Anecdote only (and not in any way intended to detract from the original message which is that it is far more likely that a sigmoid diverticulitis will be misdiagnosed as inflammatory bowel disease): I had exactly the opposite happen. About 2 years ago, I did a sigmoid colectomy (low anterior actually) for sigmoid diverticulitis in an about 50 year old healthy man. Path report showed sigmoid diverticulitis plus lymphoid hypertrophy ?malignancy reviewed by outside Pathologists who felt this was a simple diverticulitis. His symptoms had been typical of diverticulitis, intractable.

Since then, he has developed really intractable diarrhea, sometimes bloody, treated by his new family doctor repeatedly for diverticulitis (which is highly unlikely after an adequate sigmoid colectomy/low anterior resection removing all the visible diverticula). He also had a course of ampicillin for some upper respiratory symptoms and a course of plain ciprofloxacin for possible infectious diarrhea.

He however continued to have intractable diarrhea even sometimes bloody. Stool for Clostridium difficile toxin x3 was normal as were all other stool tests.

Colonoscopy showed ulcerative colitis throughout the colon (including clearly on both sides of my perfectly adequate anastomosis).

Re-review of the colectomy specimen showed no evidence of ulcerative colitis.

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