COLOUTERINE FISTULA, AN UNCOMMON CAUSE OF PNEUMOPERITONEUM
Linda Luong DO, Christina Zhu, Ariel Santos MD, Thomas Howe MD
Presenter: Linda Luong, DO, Texas Tech Lubbock
Introduction/Objective: Pneumoperitoneum with abdominal tenderness often calls for urgent surgical exploration. Usually pneumoperitoneum comes from perforated hollow viscus. Perforation of the uterus is an uncommon cause of pneumoperitoneum. Colouterine fistualization is very rare, and colouterine fistula with uterine perforation is an even more rare cause of pneumoperitoneum. This case describes a very rare complication of sigmoid diverticulitis resulting in colouterine fistula and perforation.
Case Presentation: A 88-year-old female transferred from an outside facility with a 5 day history of abdominal pain associated with nausea. The pain initially started in the lower pelvis, but became diffuse. On exam she was tender in all 4 quadrants with guarding, and rebound tenderness. Labs showed a leukocytosis of 29.6 thousand, and CT scan at the transferring facility showed pneumoperitoneum, thickened sigmoid with free fluid in the abdomen. There was concern for perforated diverticulitis and need for urgent exploration. Conversations with the patient revealed she wished for her code status to be do not resuscitate, although she wanted surgical intervention. She was taken emergently to the operating room for exploration. She had sigmoid diverticulosis with fistualization into the uterus and perforation of the uterine wall spilling feculent material into the abdomen. The cervical os was stenosed. She underwent a hysterectomy with sigmoid resection with end colostomy with the assistance from the OBGYN team. Post operatively her stay was complicated by atrial fibrillation with rapid ventricular response, respiratory complications and subsequently passed.
Discussion: Diverticulitis is inflammation or infection of diverticulum, and is a common general surgical problem. Colonic diverticulitis commonly presents with fever, left lower quadrant pain, and can be complicated by intra-abdominal abscess, pneumoperitoneum, colonic stricture, obstruction or fistulization. Colouterine fistula is a rare complication of sigmoid diverticulitis. Colouterine fistula was first described in 1909 by Lejemtel. Typical symptoms of colouterine fistulas include malodorous fecal or purulent vaginal discharge for days or months because the colonic lumen and the uterus are linked. The uterus is a very thick muscular organ, making uterine fistulas rare. In the acute care surgery and emergency general surgery world, pneumoperitoneum is often from perforated peptic ulcer disease or perforated diverticulitis. In this case, due to the stenosis of the patient’s cervical os, the presentation of her colouterine fistula presented in an atypical way. Instead of having the previously described foul vaginal drainage, she presented with acute worsening abdominal pain and peritonitis.
Conclusion: Colouterine fistula is a very rare compilation of sigmoid diverticulitis. This disease process usually presents itself as foul drainage from the vagina. In this case, the patient had no history of foul drainage from the vigina, instead she presented with abdominal pain, nausea and pneumoperitoneum. It is important to remember that although very rare, a colouterine fistula can result in pneumoperitoneum and perforation of the uterus requiring not only a colon resection but also a hysterectomy.
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