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Pyeloenteric Fistula

A pyeloenteric fistula is a rare abnormal communication between the renal pelvis (pyelo-) and a segment of the gastrointestinal tract (enteric). The most commonly described subtype is the pyeloduodenal fistula, though fistulae can also extend to the colon (renocolic) or other bowel segments.[1][2] It is the upper-tract counterpart to the more familiar enterovesical fistulas of the bladder, and almost always arises from longstanding obstructive infection or chronic calculus disease rather than from inflammatory bowel disease.

See also: The Kidneys, Fistulas landing page.

Definition and Classification​

A pyeloenteric fistula falls under the broader category of uroenteric fistulae, which are classified by the urinary-tract organ of origin and the GI-tract segment involved.[1] Specific subtypes include:

  • Pyeloduodenal fistula — the most common form, almost always involving the right kidney because of its anatomic proximity to the second portion of the duodenum[2][3]
  • Renocolic / pyelocolonic fistula — communication between the kidney and colon
  • Pyeloileal or other small-bowel fistulae — exceedingly rare

Congenital fistulae are extremely rare; the vast majority are acquired.[1]

Etiology​

The fistula most commonly arises from a chronic inflammatory process originating in the kidney:[2][3]

  • Renal calculi with chronic pyelonephritis — the most frequent cause. Staghorn calculi and recurrent infections drive perirenal abscess formation that erodes into adjacent bowel[2][3][4]
  • Renal or perirenal abscess — can erode through Gerota's fascia into the duodenum or colon[5]
  • Iatrogenic / traumatic — increasingly recognized after percutaneous nephrolithotomy (PCNL) and other interventional procedures[5]
  • Malignancy — rare; reported with renal cell carcinoma and transitional cell carcinoma of the renal pelvis[6]
  • Inflammatory bowel disease — Crohn's disease is the leading cause of uroenteric fistulae overall, but typically produces enterovesical rather than pyeloenteric communication[1][7]
  • Xanthogranulomatous pyelonephritis — destructive granulomatous process that can extend beyond the kidney into adjacent viscera

Pathogenesis​

The typical sequence is chronic renal infection or obstruction (most often from calculi) → perirenal inflammation and abscess → erosion through Gerota's fascia and the peritoneum → fistulization into the adjacent bowel wall. The right kidney's intimate relationship to the second portion of the duodenum explains the strong right-sided predominance of pyeloduodenal fistulae.[2][3]

Clinical Presentation​

Symptoms are nonspecific and overlap with those of the underlying renal disease, which makes the diagnosis easy to miss:

  • Fever, often recurrent or persistent
  • Flank pain and abdominal discomfort
  • Recurrent urinary tract infections or urosepsis[8]
  • Gastrointestinal symptoms — nausea, vomiting, diarrhea
  • Pneumaturia or fecaluria — more typical of enterovesical fistulae but can occur
  • Hematuria
  • Passage of calculi or debris per rectum — rare but pathognomonic
  • Anemia and weight loss in chronic cases[4]

Evaluation​

The diagnosis is frequently incidental, made during imaging or procedures performed for the underlying renal disease.[4][8]

ModalityRole
CT abdomen / pelvis with contrastIncreasingly the primary diagnostic tool; demonstrates the fistulous tract, perinephric inflammation, gas in the collecting system, and associated calculi or abscess[4][9]
Retrograde pyelographyHistorically the most effective study for demonstrating the tract[3]
Antegrade pyelography / nephrostographyContrast injection through a percutaneous nephrostomy tube can opacify the bowel and confirm the fistula[4][8]
Upper GI series / barium studiesMay show contrast entering the collecting system
FistulographyUseful for follow-up and confirmation of closure[8]
CystoscopyMore relevant for lower-tract uroenteric fistulae[7]

Management​

Management depends on the underlying etiology, the patient's overall condition, and the complexity of the fistula.[1][10]

Surgical management — standard of care​

  • Nephrectomy with primary closure of the duodenal or bowel defect is the most widely recommended definitive treatment, particularly when the affected kidney is nonfunctional from chronic infection or obstruction[2][3][4]
  • A multidisciplinary approach with urology and GI / colorectal surgery is recommended for complex cases[10]
  • For complex entero-urinary fistulae, a staged approach has been described: (1) proximal defunctioning and drainage to control sepsis, (2) nutritional optimization with TPN, and (3) delayed definitive reconstruction once the patient is stable[10]

Conservative and minimally invasive alternatives​

  • Ureteral stenting (internal or percutaneous) has been reported as an alternative to nephrectomy in selected cases by diverting urine and allowing the tract to heal[11]
  • Endoscopic clipping and ligation — successful closure of a pyeloduodenal fistula using endoclips and an endoloop has been reported in a patient unfit for surgery[8]
  • Percutaneous fulguration of the fistulous tract has been described as a nephron-sparing option[12]
  • Medical management — antibiotics, nutritional support, and treatment of the underlying inflammatory process (for example, immunosuppressants for Crohn's disease) may be attempted, though durable success without surgery is uncommon[1][7]

Key principles​

Adequate nutrition, eradication of sepsis, urinary-tract diversion, GI-tract diversion when needed, and treatment of the underlying cause anchor the management plan.[1]

Outcomes​

Surgical treatment generally results in durable remission. In the largest review of pyeloduodenal fistulae (28 cases), nephrectomy with duodenal closure was associated with good outcomes.[3] For complex entero-urinary fistulae managed with a staged multidisciplinary approach, all 10 patients in one series were treated successfully with no postoperative deaths.[10] Recurrence after definitive surgical repair is uncommon.

References​

1. Gill HS. "Diagnosis and Surgical Management of Uroenteric Fistula." Surg Clin North Am. 2016;96(3):583–592. doi:10.1016/j.suc.2016.02.012

2. Greene JE, Bucy JG, Wise L. "Spontaneous Pyeloduodenal and Renocolic Fistulas." South Med J. 1975;68(5):641–645. doi:10.1097/00007611-197505000-00029

3. Rodney K, Maxted WC, Pahira JJ. "Pyeloduodenal Fistula." Urology. 1983;22(5):536–539. doi:10.1016/0090-4295(83)90237-6

4. Gentile PA, Gualtieri L, Izzo S, et al. "Une Liaison Dangereuse: Spontaneous Pyeloduodenal Fistula." Dig Dis Sci. 2023;68(4):1106–1111. doi:10.1007/s10620-023-07828-1

5. Wang JH, Chiang JH, Chang T, Chen KK. "Pyeloduodenal Fistula: Report of 2 Cases." J Formos Med Assoc. 1990;89(12):1111–1114.

6. Chen CH, Cheng HL, Tong YC, Pan CC. "Spontaneous Pyeloduodenal Fistula: An Unusual Presentation in Advanced Renal Transitional Cell Carcinoma." Urology. 2002;60(2):345. doi:10.1016/s0090-4295(02)01749-1

7. Solem CA, Loftus EV, Tremaine WJ, et al. "Fistulas to the Urinary System in Crohn's Disease: Clinical Features and Outcomes." Am J Gastroenterol. 2002;97(9):2300–2305. doi:10.1111/j.1572-0241.2002.05983.x

8. Lee KN, Hwang IH, Shin MJ, et al. "Pyeloduodenal Fistula Successfully Treated by Endoscopic Ligation Without Surgical Nephrectomy: Case Report." J Korean Med Sci. 2014;29(1):141–144. doi:10.3346/jkms.2014.29.1.141

9. Yu NC, Raman SS, Patel M, Barbaric Z. "Fistulas of the Genitourinary Tract: A Radiologic Review." Radiographics. 2004;24(5):1331–1352. doi:10.1148/rg.245035219

10. Shackley DC, Brew CJ, Bryden AA, et al. "The Staged Management of Complex Entero-Urinary Fistulae." BJU Int. 2000;86(6):624–629. doi:10.1046/j.1464-410x.2000.00871.x

11. Desmond JM, Evans SE, Couch A, Morewood DJ. "Pyeloduodenal Fistulae: A Report of Two Cases and Review of the Literature." Clin Radiol. 1989;40(3):267–270. doi:10.1016/s0009-9260(89)80194-1

12. Kim SC, Weiser AC, Nadler RB. "Nephroenteric Fistula Treated With Fulguration of the Fistulous Tract." J Endourol. 2000;14(5):443–445. doi:10.1089/end.2000.14.443