A0144 - A Rare Case of Rectovesical Fistula Originating From Urothelial Carcinoma of the Bladder

Dema Shamoon, MD¹, Noreen Mirza, MD¹, Sarahi Herrera Gonzalez, MD², Jennifer Brown, DO², Andre Fedida, MD^2
1Saint Michael's Medical Center, New York Medical College, Newark, NJ; ²St. Michael's Medical Center, New York Medical College, Newark, NJ

Introduction: Rectovesical fistula an abnormal connection between the bladder and rectum. It is a complication that may be caused by laparoscopic surgery, diverticular disease, Crohn’s disease, malignant tumor invasion and states of chronic inflammation. Fistulas occurring as a complication of bladder carcinoma are a rare finding.

Case Description/Methods: A 68 year-old-male with a history of diabetes mellitus, coronary artery disease, human immunodeficiency virus, sick sinus syndrome, prostate cancer with transurethral resection and radiation, invasive urothelial cancer, stress incontinence with artificial urinary sphincter, suprapubic catheter, urinary tract infections (UTIs), and bilateral nephrostomy tubes came to the emergency department for watery non bloody diarrhea occuring 10 times daily for 1 month, weight loss and loss of appetite. Patient was anuric. On presentation, vitals were stable. Early laboratory indicated leukocytosis, acidosis, and hyperkalemia (Table 1). Urinalysis showed leukocyturia, bacteriuria, hematuria and 3+ leukocyte esterase. Urine culture was positive for Enterococcus faecium vancomycin-resistant enterococcus (VRE). Blood cultures revealed Enterococcus faecium VRE and Escherichia coli. Computed tomography (CT) of abdomen and pelvis without PO or IV contrast was negative. Infectious workup of stool including Clostridium difficile were negative. A decrease in hemoglobin prompted colonoscopy which showed a 40mm rectovesical fistula with a foley seen through the fistula and urine in the rectal vault (Images A/B/C). He had urinary diversion with bilateral nephrostomy placement along with diverting colostomy. He received palliative radiation for hematuria secondary to bladder cancer with plans for immunotherapy outpatient.

Discussion: Fistulas occurring from the bladder to the gastrointestinal (GI) tract are rare with 5% of enterovesical fistula from bladder carcinoma, frequently from urothelial carcinoma. Symptoms include recurrent UTIs, faecaluria, pneumaturia and dysuria. Less commonly, chronic watery diarrhea, melena and hematemesis. CT scan with PO or rectal contrast is the diagnostic test of choice. Endoscopic examination and cystoscopy can be useful in cases where CT scan is nondiagnostic. Treatment is individualized to each patient. Common treatments include surgical diversion of urinary and GI tracts as well as surgery. Moreover, excrement from the GI tract in the form of watery diarrhea can be a misleading symptom of rectovesical fistula in high risk patients.




Disclosures:


Dema Shamoon, MD¹, Noreen Mirza, MD¹, Sarahi Herrera Gonzalez, MD², Jennifer Brown, DO², Andre Fedida, MD². A0144 - A Rare Case of Rectovesical Fistula Originating From Urothelial Carcinoma of the Bladder, ACG 2022 Annual Scientific Meeting Abstracts. Charlotte, NC: American College of Gastroenterology.