期刊名称:Journal of Education and Teaching in Emergency Medicine
印刷版ISSN:2474-1949
出版年度:2019
卷号:4
期号:2
页码:1-3
DOI:10.21980/J80G9T
出版社:University of California Press
摘要:History of present illness: A previously healthy 39-year-old male presented to the emergency department
with six weeks ofsuprapubic pain and dysuria. He also reported passing air with his urine overthe lastseveral
days. The patient was afebrile with otherwise unremarkable vital signs. Of note, he had two prior urgent
care visits where he was diagnosed with simple urinary tract infections (UTIs) and subsequently prostatitis,
both of which have not resolved with two separate courses of antibiotics. His exam was significant for mild
suprapubic tenderness, without rebound or guarding, and an unremarkable genitourinary exam of a
circumcised male. Laboratories were significant for an abnormal urinalysis, indicating infection. Given his
history of persistent symptoms despite antibiotics, the infrequency of UTIs in healthy adult circumcised
males, and the presence of pneumaturia, a computed tomography (CT) scan of the abdomen and pelvis was
ordered.
Significant findings: A CT scan of his abdomen/pelvisshows acute sigmoid colonic diverticulitis with adjacent
extraluminal collection containing gas (axial view, white arrow) consistent with perforation, along with
abutment of the urinary bladder with intraluminal bladder gas(sagittal and coronal views, white arrowheads)
suggesting colovesical fistula.
Discussion: A colovesical fistula (CVF) is an abnormal connection between the colon and urinary bladder.1
Although uncommon, CVFs can cause significant morbidity and may lead to death, usually secondary to
urosepsis.1,2 These fistulas are most commonly complications of diverticular disease, inflammatory bowel
disease, or cancer.3 Up to 20% of patients with diverticular disease and up to 1% of patients with Crohn’s
disease are found to have a fistula.4,5 Pneumaturia or fecaluria can be seen in up to 90% of patients.6 Other
presenting signs/symptoms include dysuria, suprapubic pain, frequency, urgency, and rarely, gross
hematuria.3 The diagnosis of a colovesical fistula is confirmed by abdominopelvic CT scan with oral or rectal
contrast demonstrating air or contrast material in the bladder with adjacent colon and bladder wall
thickening. This type of diagnostic imaging has been shown to have a sensitivity of 90 to 100 percent.3
The treatment for CVF is surgical correction usually by general surgery. However, any underlying infection
resulting from the CVF should be treated with antibiotics prior to surgery.3 Antibiotic choice should cover
colonic flora, usually quinolones, or 3rd generation cephalosporins with metronidazole, or amoxicillinclavulanate can be used.3
The patient in this case was given antibiotics and admitted to the hospital with general surgery and
gastroenterology consultations. Two months later, the patient had a sigmoid colectomy and appeared to
have had a full recovery.