eMedicine Specialties > Urology > Fistulas

Renoalimentary Fistula

Author: Martha K Terris, MD, FACS, Professor, Department of Surgery, Medical College of Georgia
Coauthor(s): Matthew A Collins, MD, Staff Physician, Department of Urology, Medical College of Georgia; Sagar R Shah, MD, Staff Physician, Department of Urologic Surgery, Medical College of Georgia Health System
Contributor Information and Disclosures

Updated: Apr 23, 2009

Introduction

Fistulae between the upper urinary tract and the GI systems are rare. Iatrogenic injury is the most common etiology of renoalimentary fistula, although various pathologic processes in either organ system may lead to fistulization.5 Most renoalimentary fistulae are iatrogenic, secondary to percutaneous nephrostomy tube placement, although penetrating and blunt trauma, malignancy (particularly colon, renal, and transitional cell cancer), foreign body ingestion, and inflammatory processes (usually secondary to stones, infection, or diverticular disease) are occasionally implicated in renoalimentary fistulae.

Renoalimentary fistula has also been reported as a complication of percutaneous radiofrequency ablation and laparoscopic cryoablation. As more patients with small renal tumors are now undergoing these advanced forms of tumor treatment, surgeons should be mindful of renoalimentary fistula as a potential complication of them.41,42

If recognized early, many iatrogenic renoalimentary fistulae may be treated conservatively, obviating the need for surgery. Chronic renoalimentary fistulae are more likely to require surgery.

History of the Procedure

Hippocrates is credited for the first reported case of renoalimentary fistula in 460 BC. Renoalimentary fistulae began to be recognized more commonly in the mid 1800s and were predominantly due to renal tuberculosis (TB). A distant second cause was pyelonephritis due to infection with other organisms.1 With the exception of pyelonephritis in conjunction with stone disease, infectious causes of renoalimentary fistula diminished with advancements in antitubercular and antimicrobial therapy. As a result, renoalimentary fistulae became much less common between 1950 and 1980, with malignancy being the primary etiology. With the advent of minimally invasive renal surgery, the incidence of renoalimentary fistulae, specifically iatrogenic renoalimentary fistula, has increased. Despite the increase, this phenomenon remains quite rare.

Problem

Renoalimentary fistulae may involve any portion of the GI tract that has an abnormal connection with the kidney. The resulting drainage of urine into the GI tract, GI contents into the urinary tract, or both can lead to diarrhea, urinary tract infections, and various electrolyte abnormalities.

Frequency

Renoalimentary fistulae comprise fewer than 1% of fistulae between the urinary and intestinal tracts, the vast majority of which are colovesical fistulae.

Etiology

Most renoalimentary fistulae are iatrogenic, secondary to percutaneous nephrostomy tube placement, percutaneous radiofrequency ablation, or laparoscopic cryoablation. Trauma, foreign body ingestion, malignancy (particularly colon, renal, and transitional cell cancer), and inflammatory processes (usually secondary to stones, infection, or diverticular disease) have also been implicated in some cases.

Because the kidneys and the associated structures are normally separated from the enteric system by the peritoneum, Gerota fascia, and perirenal fat, renoalimentary fistulae tend to occur where these structures are manipulated, attenuated, or absent. Fistulization between the renal collecting system and the gut is more common in individuals who are thin or who are nutritionally debilitated. Renoalimentary fistulae are also more likely to develop in patients who have undergone renal surgery.

Renocolic fistulae are the most common type of renoalimentary fistulae.

Pathophysiology

Long-standing calculi leading to obstruction and abscess formation, xanthogranulomatous pyelonephritis (XGP), ingestion of foreign bodies (eg, toothpicks, coins, nasogastric tubes), TB, inflammatory bowel disease, peptic ulcer disease, traumatic injury to the renal collecting system or the gut, and malignancies have all been implicated in renoalimentary fistulae. A case report has described a sinus tract between the appendix and renal collecting system secondary to appendicitis.23

The most common iatrogenic cause of renoalimentary fistula is the inadvertent placement of a percutaneous nephrostomy tube through the colon. Generally, this occurs because the colon is posteriorly displaced and may even contain a retrorenal component. This anomalous anatomy is more common on the left than the right and is seen more frequently in females than in males. A retrorenal colon is more commonly encountered at the caudal aspect of the kidney.

Fistulae following radiofrequency ablation or cryoablation (see Image 3 ) are likely secondary to unrecognized bowel injury (colon or duodenum) in close approximation to the lesion being treated and are usually not discovered until follow-up imaging is performed unless they become clinically symptomatic. Tumor recurrence may also play a role in fistula formation following therapy.

CT scan of an apparent colorenal fistula followin...

CT scan of an apparent colorenal fistula following radiofrequency ablation of a small right renal tumor in a 51-year-old man. Air was found within the collecting system. Conservative treatment of the fistula was successful.

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CT scan of an apparent colorenal fistula followin...

CT scan of an apparent colorenal fistula following radiofrequency ablation of a small right renal tumor in a 51-year-old man. Air was found within the collecting system. Conservative treatment of the fistula was successful.


Another common iatrogenic cause of renoalimentary fistulae is the breakdown of anastomotic suture lines when renal and bowel surgery are performed simultaneously. Such procedures are commonly used to treat locally advanced transitional cell carcinoma of the bladder or ureter that requires intestinal interposition for urinary diversion (see Images 1-2). Patients with neurogenic bladder dysfunction or congenital abnormalities of the urinary tract may also undergo intestinal reconstruction and be at risk for fistula formation.

Renoalimentary fistula. A 61-year-old patient wit...

Renoalimentary fistula. A 61-year-old patient with a history of urinary diversion due to transitional cell carcinoma of the bladder presented with back pain and underwent a bone scan to evaluate for the presence of metastases. Bone scan findings revealed drainage of the urinary radioisotope into the colon.

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Renoalimentary fistula. A 61-year-old patient wit...

Renoalimentary fistula. A 61-year-old patient with a history of urinary diversion due to transitional cell carcinoma of the bladder presented with back pain and underwent a bone scan to evaluate for the presence of metastases. Bone scan findings revealed drainage of the urinary radioisotope into the colon.


Renoalimentary fistula. A 61-year-old patient wit...

Renoalimentary fistula. A 61-year-old patient with a history of urinary diversion due to transitional cell carcinoma of the bladder presented with back pain and underwent a bone scan to evaluate for the presence of metastases. Bone scan findings revealed drainage of the urinary radioisotope into the colon (same patient as in Image 1). Subsequent intravenous pyelography revealed contrast in the renal pelvis draining into the colon on the right.

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Renoalimentary fistula. A 61-year-old patient wit...

Renoalimentary fistula. A 61-year-old patient with a history of urinary diversion due to transitional cell carcinoma of the bladder presented with back pain and underwent a bone scan to evaluate for the presence of metastases. Bone scan findings revealed drainage of the urinary radioisotope into the colon (same patient as in Image 1). Subsequent intravenous pyelography revealed contrast in the renal pelvis draining into the colon on the right.


Ingestion of a foreign body is most likely to lead to a pyeloduodenal fistula as a result of the foreign object lodging in the duodenum with resultant inflammatory reaction that involves the duodenum and posteriorly adjacent renal pelvis.

Cutaneous extension of the fistula is reported in 10% of cases.

Presentation

The clinical presentation of a patient with a renoalimentary fistula varies. Patients may present with just abdominal pain and fever. However, in many cases, the presence of fecaluria, pneumaturia, biliuria, recurrent urinary tract infection (UTI), or watery diarrhea may be noted. Evidence of sepsis with fever and leukocytosis is common. The presence of peritoneal signs demands immediate surgical exploration.

When caused by percutaneous nephrostomy tube placement, gas and enteric contents may drain through the tube, while voided urine may or may not appear normal.

Renoalimentary fistulae due to radiofrequency ablation or cryoablation have been discovered on routine follow-up imaging and have been mostly asymptomatic.

Indications

If peritonitis is present, immediate surgical exploration is mandated. If the patient is stable, elective resection of the fistula following mechanical and antibiotic bowel preparation is preferred. An exception is renoalimentary fistulae caused by iatrogenic injury to the bowel during percutaneous nephrostomy placement. If the injury is recognized early and the patient does not display signs of peritonitis, the accepted treatment is to pull back the percutaneous tube so that it drains the renal pelvis without maintaining the fistulous connection with the colon. Conservative management has been successful in asymptomatic renoalimentary fistulae following minimally invasive procedures.

Relevant Anatomy

The kidneys are paired retroperitoneal structures with several layers of investing tissue planes that separate them from the peritoneal contents. The retroperitoneal colonic segments are usually anterior to the kidneys, and the duodenum abuts the right kidney medially and anteriorly, rendering these bowel segments susceptible to fistula formation within the kidney.

Contraindications

Patients with renoalimentary fistulae due to cancer may not heal and may develop further complications such as systemic sepsis, severe electrolyte abnormalities, and even death. The ability to completely resect the tumor at the site of the fistula is a key element to success.

If the patient is severely malnourished, the chance of successful repair is decreased significantly. If the patient is not acutely ill from the fistula, repair should be delayed until nutritional status improves. Bowel rest and parenteral nutrition may be necessary to accomplish this goal, particularly if the patient has a gastric or small-intestine fistula.

More on Renoalimentary Fistula

Overview: Renoalimentary Fistula
Workup: Renoalimentary Fistula
Treatment: Renoalimentary Fistula
Follow-up: Renoalimentary Fistula
Multimedia: Renoalimentary Fistula
References
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References

  1. Arthur GW, Morris DG. Reno-alimentary fistulae. Br J Surg. May 1966;53(5):396-402. [Medline].

  2. Bachelier MN, Carteron M, Gazaigne J, et al. [A case of renocolic fistula complicating xanthogranulomatous pyelonephritis treated by laparoscopy]. Prog Urol. Feb 2004;14(1):67-9. [Medline].

  3. Bergenfeldt M, Hakansson U, Bjorkdahl P. Successful conservative management of a pyelo-duodenal fistula. Scand J Urol Nephrol. 2003;37(2):186-8. [Medline].

  4. Biondi GC. Duodenal fistula. JAMA. 1935;104:1894-7.

  5. Bissada NK, Cole AT, Fried FA. Reno-alimentary fistula: an unusual urological problem. J Urol. Sep 1973;110(3):273-6. [Medline].

  6. Bleacher JC, Boline GB, Decter RM, Conter RL. Pyeloduodenal fistula: a previously undescribed complication of Stamm gastrostomy. J Pediatr Surg. Dec 1993;28(12):1579-81. [Medline].

  7. Cline KL, Lang EK. Renal gastric fistula caused by staghorn calculus. J Urol. Sep 2005;174(3):1107. [Medline].

  8. Corder AP. Renal abscess with gas formation secondary to acute appendicitis. Br J Urol. Jan 1987;59(1):90. [Medline].

  9. Evans PF. Spontaneous pyelo-jejunal fistula. Postgrad Med J. Nov 1990;66(781):965-7. [Medline].

  10. Gerspach JM, Bellman GC, Stoller ML, Fugelso P. Conservative management of colon injury following percutaneous renal surgery. Urology. Jun 1997;49(6):831-6. [Medline].

  11. Gibbons RP, Schmidt JD. Reno-colic and reno-colic-cutaneous fistula: report of 3 cases. J Urol. Nov 1965;94(5):520-7. [Medline].

  12. Gill IS, Remer EM, Hasan WA, et al. Renal cryoablation: outcome at 3 years. J Urol. Jun 2005;173(6):1903-7. [Medline].

  13. Gup AK, Rogers HC, Evans BB, Alley SA. Fistula involving the left kidney, small bowel and skin. South Med J. Jul 1968;61(7):748-50. [Medline].

  14. Hadar H, Gadoth N. Positional relations of colon and kidney determined by perirenal fat. AJR Am J Roentgenol. Oct 1984;143(4):773-6. [Medline].

  15. Herbert FB, Goodacre B, Neal DE Jr. Successful conservative management of nephrocolic fistula. J Endourol. Apr 2001;15(3):281-3. [Medline].

  16. Hopkins WF, Pierce JM Jr. Spontaneous pyelo-duodenal fistula: a case report. J Urol. Apr 1966;95(4):489-92. [Medline].

  17. Hopper KD, Sherman JL, Williams MD, Ghaed N. The variable anteroposterior position of the retroperitoneal colon to the kidneys. Invest Radiol. Apr 1987;22(4):298-302. [Medline].

  18. Kim SC, Weiser AC, Nadler RB. Nephroenteric fistula treated with fulguration of the fistulous tract. J Endourol. Jun 2000;14(5):443-5. [Medline].

  19. King JD. Spontaneous renoduadenal fistulas. Radiology. 1950;54:82-6.

  20. LeRoy AJ, Williams HJ Jr, Bender CE, et al. Colon perforation following percutaneous nephrostomy and renal calculus removal. Radiology. Apr 1985;155(1):83-5. [Medline].

  21. Mahnken AH, Rohde D, Brkovic D, et al. Percutaneous radiofrequency ablation of renal cell carcinoma: preliminary results. Acta Radiol. Apr 2005;46(2):208-14. [Medline].

  22. Majeed HA, Mohammed KA, Salman HA. Renocolic fistula as a complication to xanthogranulomatous pyelonephritis. Singapore Med J. Mar 1997;38(3):116-9. [Medline].

  23. Mammen A, Ponnambathayil S, Varma KK, Kumar EK. A rare complication of appendicitis: appendiculorenal sinus with renal cellulitis. Pediatr Surg Int. Jul 2005;21(7):582-4. [Medline].

  24. Mammen NI. Pyeloduodenal fistula: a case report. Ind J Urol. 2004;2:171-2.

  25. Mathews MR, Caruso DM, Vu LP, et al. Treatment challenge: pyeloduodenal fistula. Infect Urol. 2002;15(1):18-22.

  26. Mertz H. Spontaneous reno-visceral fistulae with report of two cases of reno-colic fistulae. Trans Amer Ass Genito-Urin Surg. 1931;24:115.

  27. Mooreville M, Elkouss GC, Schuster A, et al. Spontaneous renocolic fistula secondary to calculous pyonephrosis. Urology. Feb 1988;31(2):147-50. [Medline].

  28. Morris SB, Knight MJ, Shearer RJ. Pyelo-duodenal fistula: a new method of closure. Br J Urol. Apr 1994;73(4):464-5. [Medline].

  29. Newman B. Duodenorenal fistula. Pediatr Radiol. Apr 2004;34(4):343-7. [Medline].

  30. Parvey HR, Cochran ST, Payan J, et al. Renocolic fistulas: complementary roles of computed tomography and direct pyelography. Abdom Imaging. Jan-Feb 1997;22(1):96-9. [Medline].

  31. Pickard LR, Tepas JJ, Agarwal BL, Haller JA. Duodeno-renal fistula: an uncommon complication of an ingested foreign body. J Pediatr Surg. Jun 1980;15(3):337-8. [Medline].

  32. Prassopoulos P, Gourtsoyiannis N, Cavouras D, Pantelidis N. Interposition of the colon between the kidney and the psoas muscle: a normal anatomic variation studied by CT. Abdom Imaging. Sep-Oct 1994;19(5):446-8. [Medline].

  33. Pulvertaft RJ. Nephro-renal fistula. Lancet. 1935;1:24-5.

  34. Schwartz DT, Garnes HA, Lattimer JK, Roberts TW. Pyeloduodenal fistula due to tuberculosis. J Urol. Sep 1970;104(3):373-5. [Medline].

  35. Shah A, Salamut W, Rull G, et al. Spontaneous pelvi-cholecystic fistula. BJU Int. Feb 2002;89(3):322-3. [Medline].

  36. Singh G, Gordon-Harris L. Tubercular reno-colic fistula. Int J Radiol Imag. 2004;14(3):295-7.

  37. Skoog SJ, Reed MD, Gaudier FA Jr, Dunn NP. The posterolateral and the retrorenal colon: implication in percutaneous stone extraction. J Urol. Jul 1985;134(1):110-2. [Medline].

  38. Tsuchiya T, Yoh M, Ito Y, Ban Y. [Primary adenocarcinoma of the renal pelvis with a pyeloduodenal fistula: a case report]. Hinyokika Kiyo. Jun 2001;47(6):421-3. [Medline].

  39. Wise HM Jr, Shimada T. Pyeloduodenal fistula: a case report. J Urol. Jun 1967;97(6):987-9. [Medline].

  40. Young TH, Lee HS, Tang SS. Urine extravasation into the colon detected by Tc-99m DTPA scintigraphy in a pyeloduodenal fistula resulting from chronic penetrating duodenal ulcer. Clin Nucl Med. Mar 2004;29(3):198-200. [Medline].

  41. de Arruda HO, Goldman S, Andreoni C, Maia RS, Szejnfeld J, Ortiz V. Renoduodenal fistula after renal tumor ablation with radiofrequency. Surg Laparosc Endosc Percutan Tech. Oct 2006;16(5):342-3. [Medline].

  42. Vanderbrink BA, Rastinehad A, Caplin D, Ost MC, Lobko I, Lee BR. Successful conservative management of colorenal fistula after percutaneous cryoablation of renal-cell carcinoma. J Endourol. Jul 2007;21(7):726-9. [Medline].

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Further Reading

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Keywords

renoalimentary fistula, pyelocolonic fistula, pyeloduodenal fistula, pyelogastric fistula, pyelojejunal fistula, pyeloalimentary fistula, pyeloenteric fistula, pyelointestinal fistula, nephrocolonic fistula, nephroduodenal fistula, nephrojejunal fistula, nephrogastric fistula, nephroalimentary fistula, nephroenteric fistula, nephrointestinal fistula, renocolic fistula, renoduodenal fistula, renojejunal fistula, renogastric fistula, renoenteric fistula, renointestinal fistula, enterorenal fistula, colorenal fistula , duodeno-renal fistula, appendiculorenal sinus, pelvi-cholecystic fistula, iatrogenic renoalimentary fistula

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Contributor Information and Disclosures

Author

Martha K Terris, MD, FACS, Professor, Department of Surgery, Medical College of Georgia
Martha K Terris, MD, FACS is a member of the following medical societies: American Cancer Society, American College of Surgeons, American Institute of Ultrasound in Medicine, American Urological Association, New York Academy of Sciences, and Society of University Urologists
Disclosure: Nothing to disclose.

Coauthor(s)

Matthew A Collins, MD, Staff Physician, Department of Urology, Medical College of Georgia
Matthew A Collins, MD is a member of the following medical societies: Alpha Omega Alpha, American College of Surgeons, American Medical Association, American Medical Student Association/Foundation, American Urological Association, and Southern Medical Association
Disclosure: Nothing to disclose.

Sagar R Shah, MD, Staff Physician, Department of Urologic Surgery, Medical College of Georgia Health System
Sagar R Shah, MD is a member of the following medical societies: American Association of Physicians of Indian Origin, American Medical Association, American Urological Association, and Endourological Society
Disclosure: Nothing to disclose.

Medical Editor

Peter Langenstroer, MD, Associate Professor, Department of Urology, Medical College of Wisconsin
Peter Langenstroer, MD is a member of the following medical societies: American Urological Association
Disclosure: Nothing to disclose.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: Nothing to disclose.

Managing Editor

Shlomo Raz, MD, Professor, Department of Surgery, Division of Urology, University of California at Los Angeles School of Medicine
Shlomo Raz, MD is a member of the following medical societies: American College of Surgeons, American Medical Association, American Urological Association, and California Medical Association
Disclosure: Nothing to disclose.

CME Editor

J Stuart Wolf Jr, MD, FACS, David A Bloom Professor of Urology, Director of Division of Minimally Invasive Urology, Department of Urology, University of Michigan
J Stuart Wolf Jr, MD, FACS is a member of the following medical societies: American College of Surgeons, American Urological Association, Catholic Medical Association, Endourological Society, Society for Urology and Engineering, Society of Laparoendoscopic Surgeons, Society of University Urologists, and Society of Urologic Oncology
Disclosure: Terumo Corporation Consulting fee Consulting; Omeros Corporation Consulting fee Consulting

Chief Editor

Edward David Kim, MD, FACS, Professor of Surgery, Division of Urology, University of Tennessee Graduate School of Medicine; Consulting Staff, University of Tennessee Medical Center
Edward David Kim, MD, FACS is a member of the following medical societies: American College of Surgeons, American Society for Reproductive Medicine, American Society of Andrology, American Urological Association, and Tennessee Medical Association
Disclosure: Lilly Consulting fee Consulting; Astellas Consulting fee Speaking and teaching; Indevus Consulting fee Speaking and teaching

 
 
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