Reno-colic fistula in a tuberculous kidney: About a case report.

Introduction

Reno-colic fistula occurs rarely and was first described in 460 B.C. by Hippocrates. The occurrence of this condition has in recent times declined due to prompt treatment of renal pathologies before the stage of fistula formation. We herein present a case of reno-colic fistula secondary to renal tuberculosis.

Case observation

A 58-year-old female patient was admitted with clinical picture of acute pyelonephritis. She had a 7 day history of fever, left loin pain and vomiting. Physical examination revealed a sick patient with high fever and tender left loin. Routine renal biochemistry was normal. Complete blood count showed leukocytosis (14 × 109/L) with dominant polymorphs, normal hemoglobin, and thrombocytopenia (75 × 109/L). Urine analyses revealed a pyuria. A contrast-enhanced computed tomography (CT) scan of abdomen and pelvis confirmed markedly dilated left pelvicalyceal system with a reno-colic fistula and a large collection in the left perinephric space measuring 7 cm (Fig. 1). The patient was started on aggressive IV hydration and IV antibiotherapy as a treatment for severe sepsis syndrome. She underwent a left nephrectomy. The anteromedial renal cortex was found adherent to, and fistulating into the proximal descending colon. The bowel was carefully dissected from the kidney and a small enterotomy was oversewn. Pathologic report revealed chronic granulomatous inflammation with central necrosis of the kidney (Fig. 2). Antituberculous regimen was started. In 8 month, she was discharged with good response to medical therapy, and she is currently under observation.

Fig. 1

A contrast-enhanced computed tomography (CT) scan of abdomen and pelvis confirmed markedly dilated left pelvicalyceal system with a reno-colic fistula and a large collection in the left perinephric space measuring 7 cm.

Fig. 2

Chronic granulomatous inflammation with central necrosis of the kidney.

Discussion

The development of fistulous communication between the kidney and the alimentary tract is rare. In total there are about 130 reported cases. Reno-colic fistulae are the most common. The ascending and the descending colon are most frequently affected although the sigmoid colon and the caecum have been involved. The literature credits Hippocrates as reporting the first recorded case in 460 BC. In approximately 10% of reports there is associated cutaneous extension. The etiology is divided into traumatic and spontaneous. Traumatic cases form the minority and are invariably iatrogenic following open or percutaneous surgical procedure. Spontaneous reno-colic fistulae almost always arise as a consequence of primary renal pathology. Underlying cause usually is renal tuberculosis or calculous pyonephrosis. Other known causes are non-calculous pyonephrosis, perinephric abscess and rupture of hydronephrosis. Renal malignancy and papillary necrosis have been implicated in a small number of cases. The clinical signs of a reno-colic fistula are rarely diagnostic though pneumaturia and pyuria might occur. The diagnosis is nearly always made radiologically either by barium enema or retrograde pyelogram due to the higher pressures generated from these procedures than generated in the renal collecting systems on intravenous urography. Sometimes the diagnosis is made by CT scan or, if there is cutaneous extension, by fistulogram. In majority of the cases the affected kidney is non-functioning on excretion urography. The mainstay of treatment is usually surgery with nephrectomy being usually necessary as the affected kidney is often completely destroyed.

Conclusion

We concede that in recent times prompt multidrug tubercular chemotherapy has significantly retarded the incidence of spontaneous reno-colic fistula due to the disease. However, renal tuberculosis being endemic in our country, we can not dismiss altogether an insidious develop-ment of such fistulas in non-functioning retained kidneys.

Conflicts of interest

The authors declare that there are no conflicts of interest regarding the publication of this article.