SIGMOID-URACHAL-CUTANEOUS FISTULA; AN UNUSUAL COMPLICATION OF DIVERTICULAR DISEASE: A CASE REPORT
Hani Ghandour*, Jessica Chin, Jan P. Kaminski, Joaquin J. Estrada, Jared Emolo
Advocate Illinois Masonic Medical Center, Chicago, IL
There are very few cases of sigmoid-urachal fistula described. A literature review showed only 15 cases in the past 100 years. We present a patient who had a sigmoid-urachal-cutaneous fistula as a complication of diverticular disease.
An 81-year-old male with a history of chronic lymphocytic leukemia (CLL), hypertension, and hypothyroidism presented with intermittent fevers, abdominal pain, and dysuria for 4 weeks. He was vitally stable with fluctuance at the umbilicus and tenderness at the left lower quadrant. He had leukocytosis up to 48.6. Computed tomography (CT) scan showed a fluid collection adjacent to the dome of the bladder that extended to the level of the umbilicus, along with thickening of the sigmoid with diverticulosis. He failed conservative treatment and subsequently consented to an exploratory laparotomy. On exploration, he was found to have a mass just to the left of the umbilicus leading towards the pelvis and bladder. The sigmoid colon appeared to be connected to this mass. We were able to separate the sigmoid colon from this mass and identified the colo-cutaneous urachal fistula. The sigmoid was resected after adequate proximal mobilization, the mass was then taken off the abdominal wall and bladder, and an end colostomy was matured due to gross contamination and borderline hypotension. The patient did well postoperatively and had a resolution of his symptoms on his post-operative visit. The final pathology came back as acute and chronic diverticulitis with diverticular abscess formation, and a urachal cyst with chronic inflammation.
Sigmoid-Urachal fistula is a rare entity that mostly forms as a complication of acute diverticulitis. patients present with symptoms of diverticulitis and urinary tract involvement, or umbilical discharge. Diagnosis is made by clinical assessment and imaging, ideally a CT scan. The treatment is surgical with the operative approach depending on the surgeon's judgment and the extent of disease involvement. Different approaches have been reported including open or laparoscopic approaches for en-bloc resection of the fistula complex including the sigmoid, urachus, and part of the bladder; Others opted for sigmoid repair.
Intraoperative image showing the involved sigmoid and urachus after transection of the fistula.
CT scan showing uracho-sigmoid fistula with fat stranding of subcutaneous fat around the umbilicus
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