Colouterine Fistula: A Rare Complication of Acute Diverticulitis Brennan Bowker MHS, PA-C, CPAAPA1 Rebecca Orsulak MHS, PA-C, CPAAPA1 Johanna D’Addario MHS, PA-C2 1Yale New Haven Hospital, Department of Surgery, New Haven, CT 2Yale New Haven Hospital, Department of Gynecology, Obstetrics and Reproductive Sciences, New Haven, CT

Introduction Case Description Discussion

• Diverticulosis is one of the most • An 80-year-old female presented to the ED with several days of worsening abdominal pain localized to the LLQ and • Fistula formation between the colon common colonic pathologies; its suprapubic region. She denied fevers or chills and had no changes in her bowel or bladder habits. She denied and the uterus due to diverticulitis is incidence is well known to increase fecaluria and pneumaturia. She had no vaginal discharge or other gynecologic symptoms. exceptionally rare.4 with age. • Her vitals were stable. Physical exam was notable only for tenderness to palpation of the left lower quadrant. • In reported cases, most women • Complications of diverticular disease presented with feculent vaginal include bleeding, perforation, discharge. This patient presented stricture, fistula, and death. Medical History Laboratory Analysis Imaging with abdominal pain only. She did • Fistula formation is considered not have vaginal discharge, unlike uncommon in diverticulitis. However PMH: Inflammatory arthritis other cases previously described in when present, fistulization usually PSH: Non-contributory the literature. occurs between the colon and the Allergies: NKDA • Proposed etiologies for colouterine bladder.1 Medications: fistula development include:5,6 • Fistulae to the female reproductive • Prednisone 5mg PO daily 1. Rupture of the gravid uterus tract are much less common due to • Hydroxychloroquine 200mg with impaction and subsequent the thick myometrium of the uterus.2 PO daily strangulation of bowel • Fewer than 40 cases of colouterine 2. Intestinal inflammation with fistula have been reported in the Hospital Course spontaneous rupture literature.3 3. Uterine or sigmoid tumor with • It is hypothesized that women who subsequent ulceration/necrosis develop colouterine fistulae do not • She was admitted to the surgical floor for bowel rest and was 4. Radiation therapy experience the typical pain profile of given IV ceftriaxone and metronidazole. The day after admission 5. Obstetrical trauma diverticulitis because the connection her WBC count decreased, and her symptoms improved. 6. Diverticulitis between the two organs allows the • On hospital day #4 she became acutely ill with worsening pain, • Treatment of this condition is not 3 colon to decompress in situ.4 hypotension, fever of 103.2°F, and leukocytosis of 19,700mm . standardized and is highly variable. • Women most often present with • A repeat CT of the abdomen and pelvis with IV contrast revealed While antibiotics can be attempted, foul-smelling vaginal discharge. worsening of the sigmoid diverticulitis and a new fluid collection in most cases, definitive surgical surrounding the right ovary. There was gas and fluid within the management is required. uterus, suggestive of fistula. The patient was taken immediately to References the OR for exploration. • Intraoperatively, the patient was found to have an obvious Conclusion 1. Bahadursingh AM, Virgo KS, Kaminski DL, Longo WE. Spectrum of colouterine fistula. The sigmoid colon was resected, and an end disease and outcome of complicated diverticular disease. Am J Surg. 2003;186:696–701. colostomy was created (Hartmann procedure). An intraoperative Diverticulitis is one of the most 2. Woods RJ, Lavery IC, Fazio VW, Jagelman DG, Weakley FL. Internal fistulas in diverticular disease. Dis Colon Rectum. 1998;31:591- gynecology consult was obtained and a hysterectomy, left common colonic pathologies and can 596. salpingo-oophorectomy, and right salpingectomy was performed. CT Scan result in a variety of complications 3. Arakawa S, Morise Z, Isetani M, et al. Laparoscopic sigmoidectomy combined with uterus excision for colouterine • Postoperatively, she was briefly monitored in the SICU and Extensive sigmoid diverticulitis with including perforation, stricture, and fistula caused by sigmoid colon diverticulitis: a case report. Asian J Endosc Surg. 2017;10:415-419. otherwise had an uneventful recovery. She was discharged home diffuse inflammation of the sigmoid colon. fistula to surrounding structures. 4. Vilallong R, Baena JA, Fort JM, Gonzalez O, Gemar E, Carrasco MA. on hospital day #8. Multiple locules of air situated between Colouterine fistula complicating diverticulitis in elderly Fistulae to the female reproductive women. Int J Colorectal Dis. 2009;24:599-600. • Pathology confirmed the intraoperative findings of diverticulitis the sigmoid colon and the uterus suggests tract typically occurs from the sigmoid 5. Kirchner WC. Sigmoid-uterine fistula. Am J Obstet Gynecol. 1933;25:241-251. and colouterine fistula. a walled off abscess. The uterus is fluid colon to the vagina but, as seen in this 6. Hawkes SZ. Enterouterine fistula. Am J Obstet filled. Gynecol. 1946;52:150-153. • Ultimately, the patient elected not to have her ostomy reversed. case, can also affect the uterus.