Uretero Enteric Fistula

Fistulas in genitourinary tract have various anatomical locations. They can involve the upper urinary tract (kidney and ureter), lower urinary tract (bladder and urethra) or the female reproductive tract. Common causes for genitourinary tract fistula are infections, inflammatory disease, neoplasms, congenital, trauma and iatrogenic injury [1]. Patients with genitourinary tract fistulas have diversity of clinical presentation and morbidity. The abnormal communication may involve the gastrointestinal tract, vessel, lymphatics or the skin [1]. Ureter is the tubular extension of the renal collecting system which passes inferiorly and medially to connect the bladder. Normal ureter is 25 – 30cm long with a diameter measuring 2-3 mm in diameter. It is divided into upper, the abdominal ureter and the lower pelvic ureter. Abdominal ureter portion begins at the junction with renal pelvis and runs over the anterior surface of the psoas muscle in anterior perinephric space. In plain radiograph the ureter is running over the lateral third of the lumbar transverse processes and described as laterally deviated if it lies more than 1.5 cm lateral to the transverse processes and considered as medially deviated if it lies over the pedicle. The ureter is fairly constant in position although pathological process in retroperitoneum can alter its position. Pelvic ureter begins at the level where the abdominal ureter crosses the common iliac artery to enter the pelvis [2]. Uretero colic fistula can involve the duodenum, jejunum, ileum and colon. They can be caused by urinary calculi, iatrogenic trauma, radiation therapy, diverticulitis, transitional cell carcinoma and tuberculosis. The patients with uretero enteric fistula usually presents with flank pain, hematuria, recurrent urinary tract infections, fecaluria, pneumaturia and diarrhea. The diagnostic study depends on the anatomic site of origin and termination of the fistula. Fistulography is considered the gold standard method for demonstration of a fistulous tract considering its feasibility. For detection of upper tract abnormalities Intravenous urography (IVU), Pyelography or Ureterography are considered the mainstays of upper tract investigation. Voiding cystourethrography (VCUG) and urethrography are used to demonstrate the lower urinary tract. Cross sectional studies are also increasingly being used and can considered as the first line imaging modality in some cases. CT urography (CTU) with reformatted sagittal and coronal images are helpful in demonstrating ureteric leaks or fistulae.