骨盆腔放射線治療及經尿道膀胱腫瘤切除術後以肉眼 可見的血尿及糞尿為表現的腸道膀胱廔管：病例報告及文獻回顧

Enterovesical Fistula Presenting with Gross Hematuria and Fecaluria after Pelvic Radiation Therapy and Transurethral Resection of Bladder Tumor: A Case Report and Literature Review

本案例為一名75歲女性表現為肉眼可見的血尿兩天，過去病史有10年前子宮頸癌第四期接受過骨盆腔放射治療、高血壓及第2型糖尿病。病人到本院急診就醫後住院接受進一步檢查，住院後第2天膀胱鏡發現出血性膀胱炎，住院後第4天接受經尿道膀胱腫瘤切除術，病理報告顯示為膀胱急慢性發炎併出血。病人於手術後第四天出院。病人於手術後第10天出現下腹痛、肉眼可見的血尿及糞尿，安排腹部電腦斷層及腸胃道鋇劑攝影均顯示迴腸膀胱廔管。後續安排住院接受剖腹探查、廔管及迴腸切除術及膀胱修補術。病理報告顯示為迴腸憩室和潰瘍伴有急性和慢性發炎。病人於術後第7天併發膀胱出血及膀胱滲漏，經膀胱鏡清血塊及腹腔引流後，於術後第36天出院。本文討論腸道膀胱廔管的病態生理學、危險因子、常見症狀、診斷及治療、手術併發症處理等。此案例提醒基層醫師若病人有肉眼可見的血尿合併骨盆腔放射線治療的病史應鑑別診斷腸道膀胱廔管，需儘早安排腸胃道鋇劑攝影或腹部電腦斷層，以免延誤診斷時機。

 

The patient was a 75-year-old woman who presented with gross hematuria for two days. Her medical history included cervical cancer, stage IV treated with pelvic radiation therapy (RT) 10 years ago, hypertension, and type 2 diabetes mellitus. The patient visited the emergency department of our hospital on May 29, 2016, and was hospitalized for further evaluation. Cystoscopy on the 2nd day after admission revealed hemorrhagic cystitis. Transurethral resection of bladder tumor (TURBT) was performed on the 4th day after admission. The pathology report revealed acute and chronic bladder inflammation and bleeding. The patient was discharged on the 8th day after admission. However, the patient developed lower abdominal pain, gross hematuria, and fecaluria on the 10th postoperative day. Abdominal computed tomography (CT) and gastrointestinal tract (GI) series were performed, all of which showed an ileum-vesical fistula. Exploratory laparotomy, resection of the fistula and ileum, and bladder repair, were performed on June 17, 2016, fifteen days after her first operation. The surgeries were successful and uneventful. Pathological examination revealed a diverticulum and ulcer with transmural mixed acute and chronic inflammation. Unfortunately, the patient developed intraperitoneal bladder perforation on the 7th postoperative day. After adequate abdominal drainage and cystoscopy-assisted blood clot evacuation, she was discharged from the hospital on the 36th postoperative day. This article discusses the pathophysiology of enterovesical fistula, risk factors, common symptoms, diagnosis and treatment, and the management of surgical complications. Clinicians should keep this clinical scenario in mind if the patient has gross hematuria combined with a history of pelvic RT. This combination of symptoms and history should suggest a differential diagnosis of enterovesical fistula and arrangement of GI series or abdominal CT should be performed as soon as possible to avoid delaying the diagnosis.