Br. J. Surg. Vol. 66 (1979) 31-34
Pyeloduodenal fistula: a case report and review of the literature A. J . G . B ATC H, A . H. A M E R Y A N D E . R . RE D D Y " SUMMARY
A case of the rare condition of pyeloduodenal fistula is presented-the thirty-second case so far recorded in the literature. The authors consider that this instance shows some of the features typical of the cases so far reported. The literature is reviewed and the aetiology, presentation, diagnostic methods and treatment are briefly discussed.
FISTULOUS connection between the renal and alimentary tracts is itself unusual and spontaneous pyeloduodenal fistula is one of the rarer types. In an exhaustive review Abeshouse (1949) found only 9 cases of pyeloduodenal fistula in a total of 277 renoalimentary fistulas of all types. We have found only 31 reported cases (Table I ) and present here a further case, due to chronic pyonephrosis. Case report A 44-year-old man presented with sudden onset of swinging fever, general malaise, aching in the back and limbs and anorexia. After 10 days of persistent symptoms he developed right loin pain, dysuria, frequency and haematuria. These urinary symptoms settled after a course of antibiotics, but the fever and malaise continued. Ten days later he was referred to hospital for investigation. Further questioning revealed a 4-year history of recurrent febrile illnesses, each similar to his current attack, but there was no past history of urinary disorder. On admission he had a fever of 39 "C and a tender mass in the right loin. Investigations showed a haemoglobin of 11.4 g/dl and a WBC of 17.3 x 108/1. Biochemistry was normal, MSU contained red cells but no growth and an intravenous pyelogram showed a normal left renal tract but a non-functioning right kidney. Four days after admission the patient's temperature suddenly fell to normal with a dramatic improvement in his general condition unassociated with any new symptoms. Cystoscopy the same day revealed no abnormality. A retrograde pyelogram of the right side revealed a grossly distorted pelvicalyceal system and free flow of contrast medium into the duodenum (Fig. 1). Renal puncture was then performed under X-ray control: 80 ml of pus were aspirated and contrast studies confirmed the changes in the right kidney (Fig. 2). Culture of the pus yielded a heavy growth of Escherichia coli and the patient was started on a course of cephradine. He was discharged home feeling well on the seventh day. Two weeks later a further intravenous pyelogram showed a thin shell of renal tissue with large cystic spaces on the right but no clear outline of the pelvicalyceal system or ureter. Contrast medium was seen in the small bowel on later films. Although symptom-free the patient was readmitted 4 weeks after discharge from hospital for exploration of the right kidney. The kidney was approached posteriorly and dense fibrosis was encountered around it, especially at the hilum, where a fistulous connection was found between the dilated renal pelvis and the posterior aspect of the duodenum (Fig. 3). Nephrectomy was performed, dividing the fistula and repairing the duodenal defect. The patient's postoperative recovery was uneventful and he was discharged home on the tenth day. Macroscopically, the specimen revealed a grossly dilated pelvicalyceal system lined with blood clot and exudate surrounded by a thin shell of kidney tissue. The microscopic appearances were those of chronic pyonephrosis.
Discussion Cases of pyeloduodenal fistula have been divided into traumatic and spontaneous, no case of congenital fistula ever having been reported. With one exception, all the reported cases involved the right kidney. Arendt and Brockman (1934) reported a case involving the left kidney and the terminal duodenum. Traumatic fistulas form the smaller group, but since 1945 these appear to be increasing in frequency (Bissada et al., 1973). Reported cases have been due to bullet wounds (McDougal and Persky, 1972; Bissada et al., 1973), penetration of the duodenum by ingested foreign bodies (Abeshouse, 1949; Schimmel, 1971), crushing injuries (Hinton, 1866; Arthur and Morris, 1966), surgical instrumentation of the renal tract (Abeshouse, 1949; Boggs et al., 1961) and drainage of supposed pancreatic cysts (the hydronephrotic renal pelvis) into the duodenum (Morson and Stiddolph, 1951; Bissada et al., 1973). Trauma may lead to extravasation of blood or urine into the perinephric space, a perinephric abscess and eventual rupture into the duodenum (Abeshouse, 1949). This process .is similar to spontaneous fistula formation in the presence of chronic renal inflammatory disease. Probably some cases of spontaneous fistula are preceded by an episode of trauma, the diseased renal pelvis being more likely to rupture. Generally, spontaneous pyeloduodenal fistula results from a pathological process in the kidney. Only one case due to duodenal pathology is reported (von Friedman and Lefke, 1969), although Hoare (1973) reports a case of ureteroduodenal fistula ascribed to a duodenal ulcer. Tuberculosis was considered to be an important cause; there are, however, only 5 reported cases in the literature (Table I ) . Chronic renal inflammatory disease accounts for the majority of cases. Of the 31 cases we have collected 23 were due to chronic infection. Fifteen of these were associated with calculus and 10 also had a perinephric abscess. Urinary obstruction appears to be important in the pathogenesis, leading to extensive perinephritis and eventual rupture into adjacent organs (Abeshouse, 1949; Arthur and Morris, 1966). An obstructing calculus may erode through into the duodenum (Pulvertaft, 1935; McEwan, 1968). Bissada et al. (1973) have found a striking increase in the incidence of associated calculus since 1945 and suggest that, since the advent of effective chemotherapy, an obstructive element is necessary in addition to virulent infection. We consider our case to be one of chronic pyonephrosis, the pelvicalyceal system being grossly dilated with only a thin shell of renal tissue. There was no evidence of suppuration in the perinephric space and the renal pelvis was in direct apposition
* A. J. G. Batch, Kingston Hospital, Kingston on Thames, Surrey. A. H. Amery, Frimley Park Hospital, Frimley, Surrey. E. R. Reddy, Queen Elizabeth Hospital, Gateshead. Correspondence to: A. H. Amery.
32
A. J
Pyeloduodenal fistula: a case report and review of the literature A. J . G . B ATC H, A . H. A M E R Y A N D E . R . RE D D Y " SUMMARY
A case of the rare condition of pyeloduodenal fistula is presented-the thirty-second case so far recorded in the literature. The authors consider that this instance shows some of the features typical of the cases so far reported. The literature is reviewed and the aetiology, presentation, diagnostic methods and treatment are briefly discussed.
FISTULOUS connection between the renal and alimentary tracts is itself unusual and spontaneous pyeloduodenal fistula is one of the rarer types. In an exhaustive review Abeshouse (1949) found only 9 cases of pyeloduodenal fistula in a total of 277 renoalimentary fistulas of all types. We have found only 31 reported cases (Table I ) and present here a further case, due to chronic pyonephrosis. Case report A 44-year-old man presented with sudden onset of swinging fever, general malaise, aching in the back and limbs and anorexia. After 10 days of persistent symptoms he developed right loin pain, dysuria, frequency and haematuria. These urinary symptoms settled after a course of antibiotics, but the fever and malaise continued. Ten days later he was referred to hospital for investigation. Further questioning revealed a 4-year history of recurrent febrile illnesses, each similar to his current attack, but there was no past history of urinary disorder. On admission he had a fever of 39 "C and a tender mass in the right loin. Investigations showed a haemoglobin of 11.4 g/dl and a WBC of 17.3 x 108/1. Biochemistry was normal, MSU contained red cells but no growth and an intravenous pyelogram showed a normal left renal tract but a non-functioning right kidney. Four days after admission the patient's temperature suddenly fell to normal with a dramatic improvement in his general condition unassociated with any new symptoms. Cystoscopy the same day revealed no abnormality. A retrograde pyelogram of the right side revealed a grossly distorted pelvicalyceal system and free flow of contrast medium into the duodenum (Fig. 1). Renal puncture was then performed under X-ray control: 80 ml of pus were aspirated and contrast studies confirmed the changes in the right kidney (Fig. 2). Culture of the pus yielded a heavy growth of Escherichia coli and the patient was started on a course of cephradine. He was discharged home feeling well on the seventh day. Two weeks later a further intravenous pyelogram showed a thin shell of renal tissue with large cystic spaces on the right but no clear outline of the pelvicalyceal system or ureter. Contrast medium was seen in the small bowel on later films. Although symptom-free the patient was readmitted 4 weeks after discharge from hospital for exploration of the right kidney. The kidney was approached posteriorly and dense fibrosis was encountered around it, especially at the hilum, where a fistulous connection was found between the dilated renal pelvis and the posterior aspect of the duodenum (Fig. 3). Nephrectomy was performed, dividing the fistula and repairing the duodenal defect. The patient's postoperative recovery was uneventful and he was discharged home on the tenth day. Macroscopically, the specimen revealed a grossly dilated pelvicalyceal system lined with blood clot and exudate surrounded by a thin shell of kidney tissue. The microscopic appearances were those of chronic pyonephrosis.
Discussion Cases of pyeloduodenal fistula have been divided into traumatic and spontaneous, no case of congenital fistula ever having been reported. With one exception, all the reported cases involved the right kidney. Arendt and Brockman (1934) reported a case involving the left kidney and the terminal duodenum. Traumatic fistulas form the smaller group, but since 1945 these appear to be increasing in frequency (Bissada et al., 1973). Reported cases have been due to bullet wounds (McDougal and Persky, 1972; Bissada et al., 1973), penetration of the duodenum by ingested foreign bodies (Abeshouse, 1949; Schimmel, 1971), crushing injuries (Hinton, 1866; Arthur and Morris, 1966), surgical instrumentation of the renal tract (Abeshouse, 1949; Boggs et al., 1961) and drainage of supposed pancreatic cysts (the hydronephrotic renal pelvis) into the duodenum (Morson and Stiddolph, 1951; Bissada et al., 1973). Trauma may lead to extravasation of blood or urine into the perinephric space, a perinephric abscess and eventual rupture into the duodenum (Abeshouse, 1949). This process .is similar to spontaneous fistula formation in the presence of chronic renal inflammatory disease. Probably some cases of spontaneous fistula are preceded by an episode of trauma, the diseased renal pelvis being more likely to rupture. Generally, spontaneous pyeloduodenal fistula results from a pathological process in the kidney. Only one case due to duodenal pathology is reported (von Friedman and Lefke, 1969), although Hoare (1973) reports a case of ureteroduodenal fistula ascribed to a duodenal ulcer. Tuberculosis was considered to be an important cause; there are, however, only 5 reported cases in the literature (Table I ) . Chronic renal inflammatory disease accounts for the majority of cases. Of the 31 cases we have collected 23 were due to chronic infection. Fifteen of these were associated with calculus and 10 also had a perinephric abscess. Urinary obstruction appears to be important in the pathogenesis, leading to extensive perinephritis and eventual rupture into adjacent organs (Abeshouse, 1949; Arthur and Morris, 1966). An obstructing calculus may erode through into the duodenum (Pulvertaft, 1935; McEwan, 1968). Bissada et al. (1973) have found a striking increase in the incidence of associated calculus since 1945 and suggest that, since the advent of effective chemotherapy, an obstructive element is necessary in addition to virulent infection. We consider our case to be one of chronic pyonephrosis, the pelvicalyceal system being grossly dilated with only a thin shell of renal tissue. There was no evidence of suppuration in the perinephric space and the renal pelvis was in direct apposition
* A. J. G. Batch, Kingston Hospital, Kingston on Thames, Surrey. A. H. Amery, Frimley Park Hospital, Frimley, Surrey. E. R. Reddy, Queen Elizabeth Hospital, Gateshead. Correspondence to: A. H. Amery.
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