• Fistula: Communication between 2 epithelialized surfaces
• Colovesical fistula
-Most common communication between bladder and GI tract
-Diverticulitis is most common cause
-Refractory, recurrent urinary tract infection (UTI) is common presentation
• Classified by output
-High output > 500 mL/d
-Low output < 500 mL/d
• Most common causes include:
• Malnutrition also major risk factor in fistula formation/failure to heal
• Affects more men than women (3:1)
• Complicates 2-4% cases of diverticulitis
• 67-80% fistulas follow abdominal surgery
• Colovesical fistula
-Patients may be asymptomatic
-Patients may have chronic, refractory UTI and present with fecaluria, pneumaturia
-Physical exam usually not revealing
-Patient may show signs of dehydration
• Colocutaneous fistula
-Draining sinus at the skin with enteric content or stool
-Often located at wound or incision with surrounding erythema, excoriation, induration
• No pathognomonic abnormalities
• UA may reveal fecaluria, infection
• Low serum albumin, prealbumin, transferring indicative of compromised nutritional status
• Sigmoidoscopy is usually unrevealing, though may disclose inflammation or mass at the fistula site
• Cystoscopy usually fails to visualize opening
• CT may detect small amounts of air in bladder
• Contrast enema may demonstrate large fistulas but commonly misses small openings
• Fistulogram if tract is mature
• Pyelography and cystography may be used to discern connection with urinary tract
• Consider etiology of fistula formation and reasons for failed closure (eg, foreign body, radiation injury, abscess, distal obstruction, neoplasm, inflammatory conditions, epithelialization)
• CT scan to evaluate for location of fistula, possible source (eg, sigmoid diverticulitis, mass, abscess)
• Obtain nutrition status markers
• Endoscopic evaluation of GI tract, bladder
• Persistent fistulae require surgical intervention, although no need for urgent or emergent surgery
• Up to 50% of colovesical fistulas secondary to diverticulitis close spontaneously
• Treat volume loss with adequate fluid resuscitation
• Correct electrolyte abnormalities
• Improve nutritional status (low output, distal fistulas may be treated with enteral feeding); use total parenteral nutrition if high output or intolerance to enteral feeding
• Sepsis must be aggressively addressed early
• Drain abscesses
• IV antibiotics when infection present
• Open, debride, and pack infected wounds
• Control and measure fistula output
• Protect skin surrounding cutaneous fistula opening
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