Sigmoid-gluteal fistula as a
rare complication of diverticular disease
Sofía
Mansilla, Fabiana Domínguez, Nicolás Muniz, Fernando Castelli
Department
of Surgery, Médica Uruguaya Corporación de Asistencia Médica (MUCAM).
Montevideo, Uruguay
ABSTRACT
Colocutaneous
fistulas of diverticular origin are rare, especially in the absence of prior
surgery or percutaneous drainage. We report the case of a 90-year-old woman
with sigmoditis and a perforated abdominal collection in the retroperitoneum
and gluteal region.
INTRODUCTION
Diverticular
disease is common in Western countries. Its importance derives from the
infectious, inflammatory and hemorrhagic complications.1,2
Among the
infectious complications, fistulas constitute 3% of the causes of admission for
diverticular disease.3 They are the result of spontaneous or
therapeutic drainage of pericolic abscesses.
The most
common diverticular fistulas are colo-vesical (65%), followed by colo-vaginal
in hysterectomized patients.1,2 Colocutaneous fistula is rare, especially
in the absence of prior surgery or percutaneous drainage.2
CASE
A
90-year-old woman, without previous health check-ups, consulted for pain in the
lower abdomen and fever. On physical examination, she did not present signs of
sepsis or peritoneal irritation, highlighting an asymmetry due to the presence
of a painful mass in the left gluteal region with subcutaneous emphysema.
The
laboratory showed leukocytosis of 24,000 103/Ul, without organic
dysfunctions. The computed tomography (CT) revealed complicated sigmoiditis
with perforation towards the retroperitoneum, forming an abdominal collection
in the left iliac fossa that fistulized towards the gluteal region through a course
superior to the left iliac wing (Fig. 1).
With the
diagnosis of sigmoid-gluteal fistula with an intermediate cavity, surgical
drainage was performed obtaining discharge of fecal content and fetid pus.
Subsequently, lavage with saline solution, placement of a latex drainage, and packing
of the surgical wound were performed.
A
broad-spectrum empirical antibiotic was indicated for germs of the intestinal
flora (ampicillin sulbactam). The patient was discharged with an indication for
ambulatory wound care.
The authors declare no conflicts of
interest. Financial support: none
Correspondence: Sofía Mansilla. sofiamansillarud@gmail.com. Florencio Sanchez
2746 (CP 11300). Montevideo, Uruguay. Ph:+598 99 349 856.
Sofía Mansilla
ORCID 000-0002-5881-9284; Fabiana
Domínguez ORCID 0000-0002-1746-7091;
Nicolás Muniz ORCID 0000-0002-6235-1303; Fernando Castelli ORCID 0000-0002-6048-4807
Figure 1. Computed
tomography showing an abdominal collection in the left iliac fossa
(asterisk) and the fistulous orifices with the sigmoid colon and gluteal region
(arrows).
DISCUSSION
Colocutaneous
diverticular fistulas are rare and generally occur in oligosymptomatic patients
with a subacute or chronic course, so the symptoms are nonspecific. Diagnosis
is made with CT.1,2,4
Although
fistulization is an indication for surgical treatment, there are patients such
as the one described who may benefit from initial conservative treatment by
draining intra-abdominal abscesses and/or subcutaneous collections. Eventually,
delayed elective resective surgery can be considered in this group.1,2,4
REFERENCES
1. Hall J, Hardiman K, Lee
S, Lightner AM, Stocchi L, Paquette I, et al. The American Society of Colon and
Rectal Surgeons Clinical Practice Guidelines for the treatment of left-sided
colonic diverticulitis. Dis Colon Rectum. 2020; 63:728-47.
2. Coakley KM, Davis BR, Kasten KR. Complicated diverticular
disease. Clin Colon Rectal Surg. 2021; 34:96-103.
3. Underhill J, Pinzon MCM, Ritz E, Grunvald M, Jochum S,
Becerra A, et al. Defining diverticular fistula through inpatient admissions: a
population study. Surg Endosc. 2023; 37:645-52.
4. Barbalace
NM. Manejo actual de la enfermedad diverticular aguda del colon. Rev Argent
Coloproct. 2017; 28:181-91.