Appendicovesical Fistula in A Rare
Complication
Brian K. Rizen, MD; Charles
of
Childhood
Ruptured Appendix
Itzig, Jr, MD;
Peter J.
Quinn III,
MD
\s=b\ The diagnosis of appendicovesical fistula is difficult and usually delayed. This is most unfortunate, since surgery is uniformly successful. The case we report reemphasizes the diagnostic value of the rectal examination, intravenous pyelogram, and voiding cystogram in a child with subacute or chronic abdominal pain. Only an awareness of this condition on the part of the attending physician will lead to prompt diagnosis and definitive
therapy.
(Am J Dis Child 130:530-531, 1976) Intravenous
communications between the bladder and vermiform ap¬ compose approximately 5% of the various enterovesical fistulae described in the surgical literature.1 Regional enteritis (Crohn disease) should be added to Bailey's etiologic classification of acquired enteroves¬ ical fistulae.2 However, among the many causes, only appendiceal ab¬ scesses are likely to occur in child¬ hood.
Fistulous pendix
Received for
July 12, 1975.
publication Dec 31,1973; accepted
From the Children's
Hospital
of
Philadelphia
(Dr Rizen), the Department of Surgery, US Naval Hospital, Millington, Tenn (Dr Itzig), and the LeBonheur Children's Hospital, Memphis (Dr Quinn). The opinions expressed herein are those of the authors and in
no
way reflect the views of the US
Navy or the Department of Defense. Reprint requests to Children's Hospital, delphia, PA 19146 (Dr Rizen).
Phila-
pyelogram showing urinary
bladder communicating with ¡ntra-abdominal abscess cavity.
REPORT OF A CASE A 9-year-old girl experienced her first episode of moderately severe, right-sided abdominal pain almost three months prior to hospital admission. She was treated symptomatically at that time, following only a telephone consultation.
Her symptoms remitted within 48 hours and she remained free of acute symptoms for a two-month interval. When her symp¬ toms exacerbated, she came to the clinic with fever, malaise, abdominal pain, and
vomiting. Multiple clinic visits and laboratory stud¬ ies, including urine cultures, failed to reveal a definitive diagnosis. She was once again treated symptomatically. The presumptive diagnosis on admission to hospital was pyelonephritis, since a catheterized urine specimen showed innumera¬ ble white and red blood cells, although no
bacteria were seen on Gram-stained smear.
Downloaded From: http://archpedi.jamanetwork.com/ by a University of Manitoba User on 06/09/2015
Culture of this urine was subsequently sterile. Peripheral white blood cell count was 30,400/cu mm, with 90% segmented neutrophils and 6% band forms. Further history disclosed a 2-kg weight loss, intermittent lower abdominal pain, spiking fever, lethargy, and dysuria. Pneumaturia and fecaluria were denied. On physical examination, she was a pale, adequately hydrated girl with a rectal temperature of 38.5 C. The abdomen was slightly distended and bowel sounds were hyperactive, but without peristaltic rushes. There was tenderness to palpation in both lower quadrants, more pronounced on the right. Rebound tenderness was referred to both lower quadrants. The rectal examina¬ tion showed an exquisitely tender, rightsided mass, approximately 8 cm in diame¬ ter. Stool obtained was negative for occult blood. After blood and urine cultures were obtained, treatment with intravenous fluids and antibiotics was begun. Deferves¬ cence occurred within 36 hours, and the child remained afebrile throughout the remainder of her hospital course. Initial noncontrast roentgenographic ex¬ aminations of the abdomen were inter¬ preted as normal without evidence of mass or fecalith. An intravenous pyelogram on the second hospital day showed the bladder to be communicating with an abscess cavity in the right pelvic region (Figure). This was confirmed by a voiding cystogram; at this point, a Foley catheter was inserted to facilitate drainage. Two days later, the orifice of the fistula was visualized on cystocopic examination, and purulent material was seen exuding through the opening. No fecal material was
noted in the bladder, and proctoscopy was normal. A second cystoscopic examination, immediately prior to laparotomy and following antibiotics and decompression, failed to show the aforementioned fistulous communication. At surgery, the omentum was found to be interposed between the appendix and bladder. A residual abscess cavity was not present. The distal part of the appendix was dilated and, after separation from the omentum, a small perforation was noted near its tip. Fluid distention of the bladder failed to show a fistula. Postoperatively, antibiotic therapy was continued for a week. The Foley catheter was removed on the fifth postoperative day, and the patient was discharged on the seventh postoperative day. A final cystogram, two months later, showed a normalappearing bladder.
COMMENT Incidence
As of 1964, 44 cases of this entity had been described in the literature.' The 5:1 male preponderance demon¬ strates the apparent protection af¬ forded by the interposition of the uterus and adnexa between the bowel and bladder. Regarding age incidence, Parton4 reports a range of 7 to 62 years, but a single reported case5 involved a 5year-old boy. Two other childhood cases are reported in the Czechoslovakian literature."
Special Clinical Symptomatology According to Parton,4 these may be Features and
into three major categories: abdominal subacute 1. Vague, symptoms, which are not typical of acute appendicitis and are easily over¬ looked. 2. Typical urinary symptoms, such as frequency and continuous or termi¬ nal dysuria, which are common, and, rarely, fecal contamination of the urine. A history of flatus or feces per urethra is pathognomonic, but is by no means a constant feature. (It has been suggested that the infrequency of pneumaturia or fecaluria or both is caused by the effective obstruction of the lumen of the appendix by a fecal cast. This may eventually be trans¬ formed into an hourglass-shaped blad¬ der calculus.) Hematuria may occur but is secondary to the inflammation in the bladder. 3. Chronic abdominal discomfort, the symptoms of which, except for fecaluria or pneumaturia or both, are so nonspecific that the diagnosis may be undisclosed for months or years.
grouped
Roentgenographic Findings
Cystogram and barium enema are the most useful studies. The cysto¬ gram
tract,
frequently as
in
shows a fistulous Barium enema
our case.
Downloaded From: http://archpedi.jamanetwork.com/ by a University of Manitoba User on 06/09/2015
may show extrinsic pressure from an inflammatory mass, or it may show the fistulization between the barium-
appendix and bladder. (In our patient, this study was not helpful.) Recovery of barium salts from the urine after such a study is a further diagnostic aid.4 filled
Cystoscopic Findings appendicovesical fistulas, the opening is usually present on the right side of the bladder. Frequently, the In
opening
of the fistula may not be a mass of granulation tissue or a depressed necrotic region in the bladder may be the only evidence that a fistula exists.7 Pro¬ lapse of the appendiceal mucosa into the bladder may occur and mimic a seen, because
neoplasm.4
References 1. Forbes KA, Rose RJ: Appendico-vesical fistula. Ann Surg 160:801-803, 1964. 2. Bailey H: The acquired vesico-intestinal and urethrointestinal fistulae. Br J Urol 1:175-181, 1929. 3. Jaffe J, Evans AT: Appendiceal-vesical fistula. J Urol 92:295-297, 1964. 4. Parton LI: Appendico-vesical fistula: Report of a case and survey of the literature. Br J Surg 45:583-588, 1958. 5. Castleman B, Toune VW: Case records of the Massachusetts General Hospital. N Engl J Med 254:1238-1240, 1956. 6. Zvara V, Bruchacova V: AV fistula in two children. Cesk Pediatr 19:705-706, 1964. 7. Pemberton J De J, Pool T, Miller J: Vesico\x=req-\ appendiceal fistula. J Urol 44:274-278, 1940.
Complication
Brian K. Rizen, MD; Charles
of
Childhood
Ruptured Appendix
Itzig, Jr, MD;
Peter J.
Quinn III,
MD
\s=b\ The diagnosis of appendicovesical fistula is difficult and usually delayed. This is most unfortunate, since surgery is uniformly successful. The case we report reemphasizes the diagnostic value of the rectal examination, intravenous pyelogram, and voiding cystogram in a child with subacute or chronic abdominal pain. Only an awareness of this condition on the part of the attending physician will lead to prompt diagnosis and definitive
therapy.
(Am J Dis Child 130:530-531, 1976) Intravenous
communications between the bladder and vermiform ap¬ compose approximately 5% of the various enterovesical fistulae described in the surgical literature.1 Regional enteritis (Crohn disease) should be added to Bailey's etiologic classification of acquired enteroves¬ ical fistulae.2 However, among the many causes, only appendiceal ab¬ scesses are likely to occur in child¬ hood.
Fistulous pendix
Received for
July 12, 1975.
publication Dec 31,1973; accepted
From the Children's
Hospital
of
Philadelphia
(Dr Rizen), the Department of Surgery, US Naval Hospital, Millington, Tenn (Dr Itzig), and the LeBonheur Children's Hospital, Memphis (Dr Quinn). The opinions expressed herein are those of the authors and in
no
way reflect the views of the US
Navy or the Department of Defense. Reprint requests to Children's Hospital, delphia, PA 19146 (Dr Rizen).
Phila-
pyelogram showing urinary
bladder communicating with ¡ntra-abdominal abscess cavity.
REPORT OF A CASE A 9-year-old girl experienced her first episode of moderately severe, right-sided abdominal pain almost three months prior to hospital admission. She was treated symptomatically at that time, following only a telephone consultation.
Her symptoms remitted within 48 hours and she remained free of acute symptoms for a two-month interval. When her symp¬ toms exacerbated, she came to the clinic with fever, malaise, abdominal pain, and
vomiting. Multiple clinic visits and laboratory stud¬ ies, including urine cultures, failed to reveal a definitive diagnosis. She was once again treated symptomatically. The presumptive diagnosis on admission to hospital was pyelonephritis, since a catheterized urine specimen showed innumera¬ ble white and red blood cells, although no
bacteria were seen on Gram-stained smear.
Downloaded From: http://archpedi.jamanetwork.com/ by a University of Manitoba User on 06/09/2015
Culture of this urine was subsequently sterile. Peripheral white blood cell count was 30,400/cu mm, with 90% segmented neutrophils and 6% band forms. Further history disclosed a 2-kg weight loss, intermittent lower abdominal pain, spiking fever, lethargy, and dysuria. Pneumaturia and fecaluria were denied. On physical examination, she was a pale, adequately hydrated girl with a rectal temperature of 38.5 C. The abdomen was slightly distended and bowel sounds were hyperactive, but without peristaltic rushes. There was tenderness to palpation in both lower quadrants, more pronounced on the right. Rebound tenderness was referred to both lower quadrants. The rectal examina¬ tion showed an exquisitely tender, rightsided mass, approximately 8 cm in diame¬ ter. Stool obtained was negative for occult blood. After blood and urine cultures were obtained, treatment with intravenous fluids and antibiotics was begun. Deferves¬ cence occurred within 36 hours, and the child remained afebrile throughout the remainder of her hospital course. Initial noncontrast roentgenographic ex¬ aminations of the abdomen were inter¬ preted as normal without evidence of mass or fecalith. An intravenous pyelogram on the second hospital day showed the bladder to be communicating with an abscess cavity in the right pelvic region (Figure). This was confirmed by a voiding cystogram; at this point, a Foley catheter was inserted to facilitate drainage. Two days later, the orifice of the fistula was visualized on cystocopic examination, and purulent material was seen exuding through the opening. No fecal material was
noted in the bladder, and proctoscopy was normal. A second cystoscopic examination, immediately prior to laparotomy and following antibiotics and decompression, failed to show the aforementioned fistulous communication. At surgery, the omentum was found to be interposed between the appendix and bladder. A residual abscess cavity was not present. The distal part of the appendix was dilated and, after separation from the omentum, a small perforation was noted near its tip. Fluid distention of the bladder failed to show a fistula. Postoperatively, antibiotic therapy was continued for a week. The Foley catheter was removed on the fifth postoperative day, and the patient was discharged on the seventh postoperative day. A final cystogram, two months later, showed a normalappearing bladder.
COMMENT Incidence
As of 1964, 44 cases of this entity had been described in the literature.' The 5:1 male preponderance demon¬ strates the apparent protection af¬ forded by the interposition of the uterus and adnexa between the bowel and bladder. Regarding age incidence, Parton4 reports a range of 7 to 62 years, but a single reported case5 involved a 5year-old boy. Two other childhood cases are reported in the Czechoslovakian literature."
Special Clinical Symptomatology According to Parton,4 these may be Features and
into three major categories: abdominal subacute 1. Vague, symptoms, which are not typical of acute appendicitis and are easily over¬ looked. 2. Typical urinary symptoms, such as frequency and continuous or termi¬ nal dysuria, which are common, and, rarely, fecal contamination of the urine. A history of flatus or feces per urethra is pathognomonic, but is by no means a constant feature. (It has been suggested that the infrequency of pneumaturia or fecaluria or both is caused by the effective obstruction of the lumen of the appendix by a fecal cast. This may eventually be trans¬ formed into an hourglass-shaped blad¬ der calculus.) Hematuria may occur but is secondary to the inflammation in the bladder. 3. Chronic abdominal discomfort, the symptoms of which, except for fecaluria or pneumaturia or both, are so nonspecific that the diagnosis may be undisclosed for months or years.
grouped
Roentgenographic Findings
Cystogram and barium enema are the most useful studies. The cysto¬ gram
tract,
frequently as
in
shows a fistulous Barium enema
our case.
Downloaded From: http://archpedi.jamanetwork.com/ by a University of Manitoba User on 06/09/2015
may show extrinsic pressure from an inflammatory mass, or it may show the fistulization between the barium-
appendix and bladder. (In our patient, this study was not helpful.) Recovery of barium salts from the urine after such a study is a further diagnostic aid.4 filled
Cystoscopic Findings appendicovesical fistulas, the opening is usually present on the right side of the bladder. Frequently, the In
opening
of the fistula may not be a mass of granulation tissue or a depressed necrotic region in the bladder may be the only evidence that a fistula exists.7 Pro¬ lapse of the appendiceal mucosa into the bladder may occur and mimic a seen, because
neoplasm.4
References 1. Forbes KA, Rose RJ: Appendico-vesical fistula. Ann Surg 160:801-803, 1964. 2. Bailey H: The acquired vesico-intestinal and urethrointestinal fistulae. Br J Urol 1:175-181, 1929. 3. Jaffe J, Evans AT: Appendiceal-vesical fistula. J Urol 92:295-297, 1964. 4. Parton LI: Appendico-vesical fistula: Report of a case and survey of the literature. Br J Surg 45:583-588, 1958. 5. Castleman B, Toune VW: Case records of the Massachusetts General Hospital. N Engl J Med 254:1238-1240, 1956. 6. Zvara V, Bruchacova V: AV fistula in two children. Cesk Pediatr 19:705-706, 1964. 7. Pemberton J De J, Pool T, Miller J: Vesico\x=req-\ appendiceal fistula. J Urol 44:274-278, 1940.
