Management of Ureteric Small Bowel Fistula: A Case Report and Review of the Current Literature

TL;DR

A rare case of a ureteric small bowel fistula is managed successfully with conservative treatment, highlighting the need for individualized approaches in such rare conditions.

Contribution

This case report provides a novel conservative management strategy for ureteric small bowel fistulas when surgery is not feasible.

Findings

Conservative management with regular ureteric stent exchanges preserved renal function and improved quality of life.

Repeat imaging showed no evidence of persisting fistula, suggesting possible spontaneous closure.

Surgical closure was avoided due to high operative risk and patient-specific factors.

Abstract

Background: Ureteric small bowel fistulas are rare entities, with limited reports in the literature. These pathological connections between the ureter and small bowel can lead to recurrent upper urinary tract infections and pose significant diagnostic and therapeutic challenges. The primary cause of ureteric small bowel fistula formation is iatrogenic intervention, such as percutaneous nephrolithotomy (PCNL) or abdominal surgery involving tissue resection. However, they can also arise spontaneously due to local chronic inflammation and infection. Given their rarity, there is no standardised management pathway, and the treatment approach should be individualised.

Case Presentation: We present the case of a 57-year-old man presenting with a history of extensive locally advanced distal sigmoid carcinoma, managed with Hartmann's procedure with end colostomy followed by adjuvant radiotherapy and chemotherapy. He later developed a mid-ureteric small bowel fistula, presenting with urosepsis, a high-output stoma, deteriorating renal function and severe metabolic acidosis. Conservative management with regular ureteric stent exchanges every 3–4 months has successfully preserved renal function and improved his quality of life. Surgical closure was not pursued due to high operative risk, and repeat imaging has shown no evidence of persisting fistula, suggesting possible spontaneous closure.

Conclusion: The treatment options for this ureteric small bowel fistula were limited. A lifelong nephrostomy was deemed unsuitable due to incompatibility with the patient's profession, and surgical intervention was associated with significant complexity due to the patient's history of malignancy and radiotherapy-related tissue changes. Therefore, a conservative strategy involving serial ureteric stent exchanges was pursued. Early recognition and individualised treatment of ureteric-enteric fistulas are essential, as timely intervention can significantly enhance prognosis and quality of life.

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