HOME HELP FEEDBACK SUBSCRIPTIONS ARCHIVE SEARCH TABLE OF CONTENTS		QUICK SEARCH:   [advanced] Author: Keyword(s): Year:  Vol:  Page:

This Article Abstract Full Text Full Text (PDF) Submit a response Alert me when this article is cited Alert me when eLetters are posted Alert me if a correction is posted Citation Map Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Download to citation manager Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Pickhardt, P. J. Articles by Balfe, D. M. Search for Related Content PubMed PubMed Citation Articles by Pickhardt, P. J. Articles by Balfe, D. M.

Acquired Gastrointestinal Fistulas: Classification, Etiologies, and Imaging Evaluation¹

¹ From the Department of Radiology, National Naval Medical Center, 8901 Wisconsin Ave, Bethesda, MD 20889-5600 (P.J.P.); Department of Radiology, F. Edward Hébert School of Medicine, Uniformed Services University of the Health Sciences, Bethesda, Md (P.J.P.); and the Mallinckrodt Institute of Radiology, Washington University School of Medicine, St Louis, Mo (S.B., D.M.B.). Received July 12, 2001; revision requested August 20; revision received September 14; accepted October 16. Address correspondence to P.J.P. (e-mail: pjpik@hotmail.com).

View larger version (38K): [in a new window]   Figure 1. Classification of GI fistulas.

View larger version (38K): [in a new window]   Figure 2. Major causes of acquired GI fistulas.

View larger version (164K): [in a new window]   Figure 3a. Enteroenteric and enterocolic fistulas. (a) Frontal radiograph from barium-enhanced small-bowel study in a 25-year-old man with Crohn disease shows multiple fistulous tracts extending from the terminal ileum (arrowheads), converging to a small mesenteric cavity (*), and communicating with the cecum and more proximal ileum (arrows). (b) Transverse contrast-enhanced CT scan in a 24-year-old man with Crohn disease shows irregular bowel wall thickening, mesenteric infiltration, and contrast agent-filled extraluminal tracts (arrows) centered in the ileocecal region. This complex enterocolic fistula involved distal ileum, cecum, ascending colon, and sigmoid colon.

View larger version (161K): [in a new window]   Figure 3b. Enteroenteric and enterocolic fistulas. (a) Frontal radiograph from barium-enhanced small-bowel study in a 25-year-old man with Crohn disease shows multiple fistulous tracts extending from the terminal ileum (arrowheads), converging to a small mesenteric cavity (*), and communicating with the cecum and more proximal ileum (arrows). (b) Transverse contrast-enhanced CT scan in a 24-year-old man with Crohn disease shows irregular bowel wall thickening, mesenteric infiltration, and contrast agent-filled extraluminal tracts (arrows) centered in the ileocecal region. This complex enterocolic fistula involved distal ileum, cecum, ascending colon, and sigmoid colon.

View larger version (166K): [in a new window]   Figure 4a. Colocolic (double-tracking) fistula. (a) Frontal radiograph from air-contrast barium enema examination in a 50-year-old man 1 month after an episode of acute diverticulitis shows a long-segment narrowing (arrowheads) involving the sigmoid colon. At the distal aspect of the stricture, a second channel (arrow) parallels the colonic lumen, the so-called double-tracking sign. Note additional scattered diverticula. (b) Transverse contrast-enhanced CT scan obtained 1 month earlier than a during an acute episode shows pericolonic inflammatory changes and a small peridiverticular abscess (arrow). Adjacent large diverticulum (arrowhead) may represent the point of eventual fistula reentry. Perforation with a localized fistula was confirmed at surgery and pathologic examination.

View larger version (177K): [in a new window]   Figure 4b. Colocolic (double-tracking) fistula. (a) Frontal radiograph from air-contrast barium enema examination in a 50-year-old man 1 month after an episode of acute diverticulitis shows a long-segment narrowing (arrowheads) involving the sigmoid colon. At the distal aspect of the stricture, a second channel (arrow) parallels the colonic lumen, the so-called double-tracking sign. Note additional scattered diverticula. (b) Transverse contrast-enhanced CT scan obtained 1 month earlier than a during an acute episode shows pericolonic inflammatory changes and a small peridiverticular abscess (arrow). Adjacent large diverticulum (arrowhead) may represent the point of eventual fistula reentry. Perforation with a localized fistula was confirmed at surgery and pathologic examination.

View larger version (167K): [in a new window]   Figure 5. Enterocolic fistula. Spot radiograph obtained during air insufflation for air-contrast barium enema examination in a 58-year-old man shows unsuspected communication between sigmoid colon and small bowel (arrowheads). The patient had undergone successful surgical removal of an infected abdominal aortic graft 6 months earlier. Note also faint contrast agent (arrow) extending along aortic region.

View larger version (161K): [in a new window]   Figure 6a. Gastrocolic fistulas. (a) Frontal radiograph from solid-column barium enema examination in a 57-year-old man shows fistulous communication between the transverse colon and stomach via a large benign gastric ulcer (*) extending into the gastrocolic ligament. Note smooth folds radiating from the ulcer crater and absence of a gastric or colonic mass. (b) Contiguous transverse contrast-enhanced CT scans in a 59-year-old woman with abdominal pain and vomiting show pericolonic inflammatory changes surrounding a large transverse colonic diverticulum (arrows) in the gastrocolic region. The process blends imperceptibly with thickened gastric antrum (arrowheads). (c) Image from contrast-enhanced enema examination in the same patient as in b shows gastrocolic fistula (arrowhead), which proved to be secondary to diverticulitis at surgery and pathologic examination.

View larger version (157K): [in a new window]   Figure 6b. Gastrocolic fistulas. (a) Frontal radiograph from solid-column barium enema examination in a 57-year-old man shows fistulous communication between the transverse colon and stomach via a large benign gastric ulcer (*) extending into the gastrocolic ligament. Note smooth folds radiating from the ulcer crater and absence of a gastric or colonic mass. (b) Contiguous transverse contrast-enhanced CT scans in a 59-year-old woman with abdominal pain and vomiting show pericolonic inflammatory changes surrounding a large transverse colonic diverticulum (arrows) in the gastrocolic region. The process blends imperceptibly with thickened gastric antrum (arrowheads). (c) Image from contrast-enhanced enema examination in the same patient as in b shows gastrocolic fistula (arrowhead), which proved to be secondary to diverticulitis at surgery and pathologic examination.

View larger version (160K): [in a new window]   Figure 6c. Gastrocolic fistulas. (a) Frontal radiograph from solid-column barium enema examination in a 57-year-old man shows fistulous communication between the transverse colon and stomach via a large benign gastric ulcer (*) extending into the gastrocolic ligament. Note smooth folds radiating from the ulcer crater and absence of a gastric or colonic mass. (b) Contiguous transverse contrast-enhanced CT scans in a 59-year-old woman with abdominal pain and vomiting show pericolonic inflammatory changes surrounding a large transverse colonic diverticulum (arrows) in the gastrocolic region. The process blends imperceptibly with thickened gastric antrum (arrowheads). (c) Image from contrast-enhanced enema examination in the same patient as in b shows gastrocolic fistula (arrowhead), which proved to be secondary to diverticulitis at surgery and pathologic examination.

View larger version (93K): [in a new window]   Figure 7. Colovesical fistula. Transverse contrast-enhanced CT scans in a 56-year-old-man with pneumaturia and prior diverticulitis show air (arrowhead) in the bladder and the site of fistulous communication (arrow) between sigmoid colon and bladder. Note diverticulosis of the sigmoid colon.

View larger version (142K): [in a new window]   Figure 8a. Enterovesical fistula. (a) Contiguous transverse CT scans obtained with intravenous and oral contrast agents in a 69-year-old woman with longstanding Crohn disease show a heterogeneous soft-tissue mass (M) associated with thickened ileal loops and adjacent bladder wall thickening (arrowhead). A small gas bubble (arrow) is present in the bladder lumen. (b) Fluoroscopic image shows contrast agent injection through a communicating enterocutaneous fistula and demonstrates the fistula (arrowhead) between the ileal segment and bladder. Small-bowel adenocarcinoma complicating Crohn disease was proved at surgery.

View larger version (146K): [in a new window]   Figure 8b. Enterovesical fistula. (a) Contiguous transverse CT scans obtained with intravenous and oral contrast agents in a 69-year-old woman with longstanding Crohn disease show a heterogeneous soft-tissue mass (M) associated with thickened ileal loops and adjacent bladder wall thickening (arrowhead). A small gas bubble (arrow) is present in the bladder lumen. (b) Fluoroscopic image shows contrast agent injection through a communicating enterocutaneous fistula and demonstrates the fistula (arrowhead) between the ileal segment and bladder. Small-bowel adenocarcinoma complicating Crohn disease was proved at surgery.

View larger version (142K): [in a new window]   Figure 9. Rectovesical fistula. Transverse contrast-enhanced CT scan in a 65-year-old-man with ulcerative colitis shows air in a fistulous tract (arrow) between inflamed rectum and bladder. Note also air (arrowheads) in bladder lumen.

View larger version (163K): [in a new window]   Figure 10a. Ureteroduodenal fistula. (a) Frontal radiograph obtained after retrograde contrast agent injection of right upper urinary collecting system in a 67-year-old man shows contrast agent within the duodenum (arrows) from an unsuspected fistula. Note wire (black arrowheads) and small amount of retained contrast agent (white arrowhead) in the collecting system. (b) Contrast-enhanced CT scan performed after a shows site of contact (white arrowhead) between duodenum and right ureter. The fistula likely resulted from injury during previous aortofemoral bypass surgery. Note vascular graft (black arrowhead) and right ureteral stent (arrow).

View larger version (169K): [in a new window]   Figure 10b. Ureteroduodenal fistula. (a) Frontal radiograph obtained after retrograde contrast agent injection of right upper urinary collecting system in a 67-year-old man shows contrast agent within the duodenum (arrows) from an unsuspected fistula. Note wire (black arrowheads) and small amount of retained contrast agent (white arrowhead) in the collecting system. (b) Contrast-enhanced CT scan performed after a shows site of contact (white arrowhead) between duodenum and right ureter. The fistula likely resulted from injury during previous aortofemoral bypass surgery. Note vascular graft (black arrowhead) and right ureteral stent (arrow).

View larger version (137K): [in a new window]   Figure 11. Rectovaginal fistula. Lateral radiograph from air-contrast barium enema examination in a 38-year-old woman with ulcerative colitis shows air and contrast agent within the vagina (V). The site of communication (arrow) is visible inferiorly. The rectosigmoid region appears somewhat foreshortened and featureless.

View larger version (154K): [in a new window]   Figure 12. Salpingocolic (colotubal) fistula. Frontal pelvic radiograph from hysterosalpingogram in a 28-year-old woman with a history of pelvic inflammatory disease shows left hydrosalpinx and contrast agent filling a tubo-ovarian abscess cavity (A), with extension superiorly into the left side of the colon (arrowheads).

View larger version (142K): [in a new window]   Figure 13. Rectourethral fistula. Oblique radiograph from retrograde urethrogram in a 64-year-old man with a history of brachytherapy for prostate cancer shows contrast agent in the rectum (arrowheads). Contrast agent entered the rectum via a large communication with the prostatic urethra (arrow). As expected, contrast agent is also present in the anterior urethra and bladder (B). Note radiopaque brachytherapy implants in prostatic region.

View larger version (124K): [in a new window]   Figure 14a. Gallstone ileus from cholecystoduodenal fistula. (a) Supine radiograph in a 76-year-old woman shows bowel gas pattern suggestive of small-bowel obstruction, two ectopic calcified gallstones (arrowheads), and air in the biliary tree (arrows). These findings constitute the Rigler triad. (b) Transverse CT scans obtained without intravenous contrast agent in an 85-year-old woman show pneumobilia (arrowheads) and high-grade small-bowel obstruction from an ectopic gallstone (short arrow). Note also orthotopic gallstones (long arrow) with a similar appearance.

View larger version (129K): [in a new window]   Figure 14b. Gallstone ileus from cholecystoduodenal fistula. (a) Supine radiograph in a 76-year-old woman shows bowel gas pattern suggestive of small-bowel obstruction, two ectopic calcified gallstones (arrowheads), and air in the biliary tree (arrows). These findings constitute the Rigler triad. (b) Transverse CT scans obtained without intravenous contrast agent in an 85-year-old woman show pneumobilia (arrowheads) and high-grade small-bowel obstruction from an ectopic gallstone (short arrow). Note also orthotopic gallstones (long arrow) with a similar appearance.

View larger version (145K): [in a new window]   Figure 15. Cholecystocolic fistula. Spot radiograph from barium enema examination in an 81-year-old man with nonspecific abdominal complaints shows contrast agent within the gallbladder (*) from communication with the hepatic flexure. Air (arrowheads) is present within the biliary tree.

View larger version (132K): [in a new window]   Figure 16a. Primary and secondary aortoduodenal fistulas. (a) Primary aortoduodenal fistula. Transverse nonenhanced CT scan in an 80-year-old woman with GI bleeding shows a calcified abdominal aortic aneurysm (A) with intraluminal gas (arrow). Massive high-attenuation retroperitoneal hemorrhage (H) surrounds the aorta. (b) Secondary aortoduodenal fistula. Contiguous transverse contrast-enhanced CT scans in a 71-year-old man with GI bleeding and history of aortic repair shows air (black arrow) in the lumen of the aortic graft and tethering (white arrow) of overlying duodenum associated with periaortic inflammatory changes.

View larger version (144K): [in a new window]   Figure 16b. Primary and secondary aortoduodenal fistulas. (a) Primary aortoduodenal fistula. Transverse nonenhanced CT scan in an 80-year-old woman with GI bleeding shows a calcified abdominal aortic aneurysm (A) with intraluminal gas (arrow). Massive high-attenuation retroperitoneal hemorrhage (H) surrounds the aorta. (b) Secondary aortoduodenal fistula. Contiguous transverse contrast-enhanced CT scans in a 71-year-old man with GI bleeding and history of aortic repair shows air (black arrow) in the lumen of the aortic graft and tethering (white arrow) of overlying duodenum associated with periaortic inflammatory changes.

View larger version (154K): [in a new window]   Figure 17a. Aortoesophageal fistula. (a) Transverse contrast-enhanced CT scan in a 52-year-old man with hematemesis and prior repair of thoracic aortic aneurysm with an endoluminal stent-graft shows air (arrowhead) in the aortic lumen adjacent to the stent-graft. Irregular air collection is also present in the expected region of the esophagus (arrow). (b) Oblique radiograph from contrast-enhanced esophagogram directly demonstrates aortoesophageal fistula (arrows), which was confirmed at surgery.

View larger version (173K): [in a new window]   Figure 17b. Aortoesophageal fistula. (a) Transverse contrast-enhanced CT scan in a 52-year-old man with hematemesis and prior repair of thoracic aortic aneurysm with an endoluminal stent-graft shows air (arrowhead) in the aortic lumen adjacent to the stent-graft. Irregular air collection is also present in the expected region of the esophagus (arrow). (b) Oblique radiograph from contrast-enhanced esophagogram directly demonstrates aortoesophageal fistula (arrows), which was confirmed at surgery.

View larger version (157K): [in a new window]   Figure 18. Colovenous fistula. Postevacuation radiograph from barium enema examination shows contrast agent throughout the inferior mesenteric venous system (arrowheads). Colovenous fistula was due to diverticulitis. Note extensive sigmoid diverticulosis in this region. (Case courtesy of Charles A. Rohrmann, MD, Seattle, Wash.)

View larger version (109K): [in a new window]   Figure 19a. Tracheoesophageal and bronchoesophageal fistulas. (a) Lateral radiograph from barium esophagogram in a 61-year-old man with esophageal cancer shows contrast agent delineating tracheoesophageal communication (arrowhead). Note widening of tracheoesophageal stripe (*) and mass effect on the trachea from tumor. (b) Lateral radiograph from barium esophagogram in a 61-year-old man with recurrent pneumonia shows fistula (arrow) between esophagus and airway that was secondary to histoplasmosis. (c) Reformatted oblique transverse multi-detector row helical CT scan in a 47-year-old man with bronchogenic carcinoma shows irregular fistulous tract extending from the left bronchial tree (black arrowhead) to the esophagus (black arrow). Five standard transverse CT images (not shown) were needed to sequentially demonstrate the oblique course displayed on this single reformatted image. Note oral contrast agent (white arrow) in segmental bronchus and peripheral airspace consolidation (white arrowhead). The patient was treated with a covered esophageal stent.

View larger version (113K): [in a new window]   Figure 19b. Tracheoesophageal and bronchoesophageal fistulas. (a) Lateral radiograph from barium esophagogram in a 61-year-old man with esophageal cancer shows contrast agent delineating tracheoesophageal communication (arrowhead). Note widening of tracheoesophageal stripe (*) and mass effect on the trachea from tumor. (b) Lateral radiograph from barium esophagogram in a 61-year-old man with recurrent pneumonia shows fistula (arrow) between esophagus and airway that was secondary to histoplasmosis. (c) Reformatted oblique transverse multi-detector row helical CT scan in a 47-year-old man with bronchogenic carcinoma shows irregular fistulous tract extending from the left bronchial tree (black arrowhead) to the esophagus (black arrow). Five standard transverse CT images (not shown) were needed to sequentially demonstrate the oblique course displayed on this single reformatted image. Note oral contrast agent (white arrow) in segmental bronchus and peripheral airspace consolidation (white arrowhead). The patient was treated with a covered esophageal stent.

View larger version (140K): [in a new window]   Figure 19c. Tracheoesophageal and bronchoesophageal fistulas. (a) Lateral radiograph from barium esophagogram in a 61-year-old man with esophageal cancer shows contrast agent delineating tracheoesophageal communication (arrowhead). Note widening of tracheoesophageal stripe (*) and mass effect on the trachea from tumor. (b) Lateral radiograph from barium esophagogram in a 61-year-old man with recurrent pneumonia shows fistula (arrow) between esophagus and airway that was secondary to histoplasmosis. (c) Reformatted oblique transverse multi-detector row helical CT scan in a 47-year-old man with bronchogenic carcinoma shows irregular fistulous tract extending from the left bronchial tree (black arrowhead) to the esophagus (black arrow). Five standard transverse CT images (not shown) were needed to sequentially demonstrate the oblique course displayed on this single reformatted image. Note oral contrast agent (white arrow) in segmental bronchus and peripheral airspace consolidation (white arrowhead). The patient was treated with a covered esophageal stent.

View larger version (148K): [in a new window]   Figure 20a. Esophagopleural fistulas. (a) Transverse nonenhanced CT scan in a 43-year-old woman shows large air-fluid collection in left pleural space (P) that encroaches on the esophagus (arrow). (b) Subsequent esophagogram shows contrast agent leak (arrowheads) from the distal esophagus into empyema. (c) Transverse contrast-enhanced CT scan in a 29-year-old man with a history of radiation therapy for Hodgkin disease shows communication (arrow) between esophagus and apical hydropneumothorax (P). L = aerated right upper lobe.

View larger version (155K): [in a new window]   Figure 20b. Esophagopleural fistulas. (a) Transverse nonenhanced CT scan in a 43-year-old woman shows large air-fluid collection in left pleural space (P) that encroaches on the esophagus (arrow). (b) Subsequent esophagogram shows contrast agent leak (arrowheads) from the distal esophagus into empyema. (c) Transverse contrast-enhanced CT scan in a 29-year-old man with a history of radiation therapy for Hodgkin disease shows communication (arrow) between esophagus and apical hydropneumothorax (P). L = aerated right upper lobe.

View larger version (127K): [in a new window]   Figure 20c. Esophagopleural fistulas. (a) Transverse nonenhanced CT scan in a 43-year-old woman shows large air-fluid collection in left pleural space (P) that encroaches on the esophagus (arrow). (b) Subsequent esophagogram shows contrast agent leak (arrowheads) from the distal esophagus into empyema. (c) Transverse contrast-enhanced CT scan in a 29-year-old man with a history of radiation therapy for Hodgkin disease shows communication (arrow) between esophagus and apical hydropneumothorax (P). L = aerated right upper lobe.

View larger version (175K): [in a new window]   Figure 21a. Gastropericardial and esophagopericardial fistulas. (a) Transverse contrast-enhanced CT scan in an 82-year-old woman with spontaneous pneumopericardium (P) shows hiatal hernia with inflammatory changes (arrowheads) adjacent to the pericardium. Gastropericardial communication (arrow) is suggested and was confirmed at fluoroscopic examination with water-soluble contrast agent (not shown). A penetrating benign gastric ulcer was the underlying cause. (b) Oblique esophagogram in a 73-year-old man with spontaneous pneumopericardium after distal esophagectomy for cancer shows contrast agent filling the pericardial space (arrowheads) via the esophagopericardial fistula. (Case courtesy of Charles A. Rohrmann, MD, Seattle, Wash.)

View larger version (150K): [in a new window]   Figure 21b. Gastropericardial and esophagopericardial fistulas. (a) Transverse contrast-enhanced CT scan in an 82-year-old woman with spontaneous pneumopericardium (P) shows hiatal hernia with inflammatory changes (arrowheads) adjacent to the pericardium. Gastropericardial communication (arrow) is suggested and was confirmed at fluoroscopic examination with water-soluble contrast agent (not shown). A penetrating benign gastric ulcer was the underlying cause. (b) Oblique esophagogram in a 73-year-old man with spontaneous pneumopericardium after distal esophagectomy for cancer shows contrast agent filling the pericardial space (arrowheads) via the esophagopericardial fistula. (Case courtesy of Charles A. Rohrmann, MD, Seattle, Wash.)

View larger version (147K): [in a new window]   Figure 22. Pancreaticocolocutaneous fistula. Frontal radiograph from barium enema examination in a 55-year-old man with severe pancreatitis shows contrast agent filling an irregular retroperitoneal collection (*) extending from the region of the pancreatic tail. Communication with the pancreatic ductal system is not apparent. Note also colocutaneous fistula (arrowheads).

View larger version (168K): [in a new window]   Figure 23. Enterocutaneous fistula. Oblique radiograph from pelvic fistulogram in a 29-year-old man with abdominal tuberculosis shows enterocutaneous fistula (arrowheads). Note second cutaneous fistula (arrow) that communicates with injection site.

View larger version (148K): [in a new window]   Figure 24a. Gastrocutaneous and colocutaneous fistulas. (a) Transverse contrast-enhanced CT scan in a 65-year-old woman with Crohn disease shows unsuspected gastrocutaneous fistula (F). Note soft-tissue thickening (arrowheads) of the abdominal wall and stomach. A focal abdominal bulge was initially thought at clinical examination to be a ventral hernia because overlying skin was still intact at that time. (b) Transverse contrast-enhanced CT scan in a 78-year-old man who had previously undergone surgery for abdominal wall abscess shows enteric contrast agent (arrow) outlining a colocutaneous fistula involving the sigmoid colon (S) and an abdominal wound. Diverticulitis was the underlying cause for both the original abscess and recurrent fistula.

View larger version (167K): [in a new window]   Figure 24b. Gastrocutaneous and colocutaneous fistulas. (a) Transverse contrast-enhanced CT scan in a 65-year-old woman with Crohn disease shows unsuspected gastrocutaneous fistula (F). Note soft-tissue thickening (arrowheads) of the abdominal wall and stomach. A focal abdominal bulge was initially thought at clinical examination to be a ventral hernia because overlying skin was still intact at that time. (b) Transverse contrast-enhanced CT scan in a 78-year-old man who had previously undergone surgery for abdominal wall abscess shows enteric contrast agent (arrow) outlining a colocutaneous fistula involving the sigmoid colon (S) and an abdominal wound. Diverticulitis was the underlying cause for both the original abscess and recurrent fistula.

View larger version (154K): [in a new window]   Figure 25. Transsphincteric perianal fistula. Coronal dynamic contrast-enhanced gradient-echo MR image obtained with fat suppression in 34-year-old man without a history of Crohn disease shows a left-sided fistula (arrow) that pierces both sphincteric layers to exit the middle third of the anus. The fistula tracks inferiorly within the ischiorectal fossa. Note conspicuity of high-signal-intensity lesion due to inflammatory enhancement. (Case courtesy of John A. Spencer, MD, Leeds, England.)