Duodenal and Common Bile Duct Obstruction with a Pyelo-duodenal Fistula caused by Renal Calculous Pyonephrosis An 83-year-old lady presented with a 10-day history of epigastric pain, vomiting and constipation. On examination she was slightly dehydrated and had vague generalised abdominal tenderness with a succussion splash. A diagnosis of pyloric stenosis was made. Initially she was treated conservatively with a sat isfactory result. An X-ray of the abdomen taken on admission showed a staghorn calculus in the right kidney. There was gross distension of the stomach which appeared to extend into and include the first part of the duodenum. A barium meal (Fig.) taken 1 week after admission revealed a very large gastric residue and showed that the stomach and first part of the duodenum were dilated and that the second part of the duodenum was obstructed. There were small pools of barium in the body of the stomach and duodenal bulb and also a third tapered pool of barium demonstrated the obstruction in the second part of the duodenum. A laparotoniy confirmed that the second part of the duodenum was obstructed and that the stomach and first part of the duodenum were grossly distended. The obstructing agent was found to be adhesions between the right renal pelvis and second part of the duodenum. On dividing these adhesions a pyeloduodenal fistula was opened but this was subsequently closed since excision and repair were thought impractical. The obstruction was by-passed by a retrocolic duodeno-jejunostoniy between the proximal jejunum and the first part of the duodenum. Initially the patient progressed well but 3 weeks following the operation she became jaundiced. Liver function tests revealed an obstructive picture. After scveral weeks the jaundice started to resolve but the patient's condition gradually deteriorated and she died. An autopsy confirmed that there was a fistulous connection between the renal pelvis and the duodenum and demonstrated that the duodenum and common bile duct were surrounded by dense adhesions which arose from a right perinephric abscess. The immediate cause of death was pulmonary embolus.

fistula has not been reported previoudy. McEwan (1968) reviewed 24 cases of s p o n taneous pyelo-duodenal fistula in the world literature and discussed aetiology and nianagement. Patients usually present with nonspecific gastro-intestinal symptonis which :trc associated with chronic renal sepsis and a l s o on occasions the flow of urine into thc duodenum gives rise to a hyperchloraemic acidosis (Boggs, Blundon and Davis. I96 I 1. K. P. BOAIIDMAN M a i i c h r s / ~ rRoyal Iiifiritiary, Afuirrlic..s/cr M 13 OII 'I

I would like to thank M r N . C . Keddie, Consultant Surgeon, Manchester Royal Infirmary, for hi\ permission to present this case.

References B o c ~ s ,J. E., BLUNDON. K. E. and DAVIS,D. M . (1961). Pyelo-duodenal fistula. ~ ~ ~ ~ t r i i u l ~ ~ 86, 199-204. MCEWANA. J. (1968). Pyelo-duodenal fistula. Brirhli Jo/triia/ O / U ~ O I O 40,~ 3.50-353 ~,

Comment

Organic obstruction of the duodenum is rare and the combination of duodenal and common bile duct obstruction caused by renal sepsis and associated with a pyelo-duodenal 6

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Duodenal and common bile duct obstruction with a pyelo-duodenal fistula caused by renal calculous pyonephrosis.

Duodenal and Common Bile Duct Obstruction with a Pyelo-duodenal Fistula caused by Renal Calculous Pyonephrosis An 83-year-old lady presented with a 10...
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