Presentation
Diabetic patient with bilateral loin pain, dysuria, frequency and fever.
Patient Data
Laboratory tests revealed high SGPT 47 U/L and SGOT 100 U/L, normal alkaline phosphatase 45 IU/L, normal bilirubin 0.4 mg/dL, mild hypocalcaemia 8.4 mg/dL, vitamin D deficiency 6 ng/mL, and hypoalbuminaemia 2.5 g/dL.
The urinary bladder showed decreased capacity with mass-like irregular wall thickening involving its upper half mainly its dome with surrounding inflammatory changes, misty mesentery and minimal pelvic fluid. Its mural thickening reaches 4 cm. It entangles the proximal sigmoid colon with obvious luminal connection transmitting bladder contrast to sigmoid colon and air into urinary bladder, consistent with colovesical fistula.
Both kidneys show multiple areas of decreased enhancement on delayed phases (striated nephrogram) more on right kidney, suggestive of pyelonephritis.
Mild bilateral hydronephrosis, likely secondary to involvement of both vesicoureteric junctions by bladder wall thickening.
Submucosal fat infiltration of the ascending colon, raising the possibility of chronic inflammatory bowel disease. No active inflammatory bowel changes.
Case Discussion
Obvious colovesical fistula between bladder dome and proximal sigmoid colon with marked vesical mural thickening involving its dome. There are two suggested possibilities:
colovesical fistula due to inflammatory bowel disease with 2ry marked cystitis forming mass-like bladder dome mural thickening and fistula formation
bladder dome neoplastic lesion with 2ry colovesical fistula supported by marked mural thickening of the bladder dome
Cystoscopic biopsy was recommended to differentiate. Unfortunately, the patient passed away after few days due to sepsis.
The striated nephrogram of both kidneys is suggestive of pyelonephritis secondary to colovesical fistula.
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