British Journal of Radiology (2007) 80, e1-e3
© 2007 British Institute of Radiology
doi: 10.1259/bjr/65194982
An unusual case of pneumoperitoneum: nephrocolic fistula due to a giant renal staghorn calculus
C Alster, MD, PhD,
L F C Zantut, MD, PhD,
F Lorenzi, MD, PhD,
G S Marchini, MD,
B J M Onofrio, MD,
A A Nakashima, MD,
B E O Gatto, MD and
D Birolini, MD, PhD
University of Sao Paolo, Sao Paolo, SP 05410-020, Brazil
Correspondence: Dr Clarissa Alster, General Surgery and Trauma, University of Sao Paolo, Arruda Alvim 107 ap. 111, Sao Paolo, SP 05410-020, Brazil. E-mail: alster{at}usp.br
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Abstract
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Gastrointestinal perforations usually lead to pneumoperitoneum and peritonitis. Rarely, if ever described, a complete giant staghorn renal stone might cause a nephrocolic fistula with sigmoid impaction and perforation similar to gallstone ileus. Few nephrointestinal fistulae have been described in the literature and none of them were presented as an acute abdomen with pneumoperitoneum and pneumoretroperitoneum. To our knowledge, this is the only case showing CT and radiographic findings of a pathology not yet described in the literature. We named the sigmoid perforation by a renal stone ileus "Lorenzi's syndrome" after the physician who hypothesized this rare differential diagnosis based only on history and clinical examination.
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Case report
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A 67-year-old white woman presented at the Hospital das Clinicas, University of Sao Paulo Medical School, in November 2001 with a 3 h sudden and continuous abdominal mesogastric pain (later diffuse) accompanied by nausea which woke her up at 4:00 am. Past medical history showed a right giant renal calculus, systemic hypertension (treated with diuretics) and a 50-year history of smoking (1 pack per day). She had been examined at urology clinics for 1 year and had been scheduled for nephrectomy several times, but had refused surgery.
Physical examination demonstrated a non-febrile, orientated, obese (body mass index (BMI) = 35) and agitated lady in pain. The abdomen was slightly distended with increased bowel sounds, guarding and signs of generalized peritonitis. Urinalysis showed infection with Proteus mirabilis.
Radiology examination (Figure 1b
) at the Emergency Room (ER) revealed a 10 cm giant renal stone in the lower pelvis similar to a bladder calculus except for the signs of pneumoperitoneum. We were able to compare the ER radiographs and abdominal CT with those examinations taken 1 year previously (Figures 1a and 2a). Abdominal CT showed the calculus impacted at sigmoid level (Figure 2a), suggesting a fistula between the right kidney and the colon which was missed previously, but could be suspected in Figure 2a (arrow).
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Figure 1. Radiology: (a) previous abdominal radiograph while the patient was seen at urology clinics which shows a right 10 cm renal stone; (b) abdominal radiograph at the ER with signs of pneumoperitoneum and pneumoretroperitoneum as well as the calculus impacted at the lower pelvis. Diagnosis: nephrocolic fistula and bowel perforation.
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Figure 2. CT: (a) abdominal CT taken 1 year prior to ER admission. Note the 10 cm calculus located at the renal pelvis on the right kidney, near the ascending colon where a fistula was forming (arrow) but was missed at that time. The renal parenchyma was atrophic. (b) Abdominal CT at the ER: the renal stone is impacted at the rectalsigmoid junction (arrow).
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At surgery a midline laparotomy was performed. Antibiotics were administered. Surgical findings were: (1) clear fluid near the sigmoid perforation with a giant calculus impacted at that area; (2) adherences among kidney, colon and duodenum; a sigmoidectomy was performed together with a right nephrectomy and right hemicolectomy. The patient recovered well from surgery except for a wound infection on day 7. On day 10 she developed a left temporal brain ischaemic attack due to an atrial fibrillation which was treated with heparin and procainamide. She was discharged from the hospital on day 31 on oral anticoagulants and antiarrythmic drugs.
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Discussion
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We found 77 papers describing fistulae between the kidney and the gastrointestinal tract published in literature (mainly Japanese). We used nephrocolic fistula, renal ileus, renocolic and renal fistula as the search criteria in Medline, Lilacs and Embase. 34 were nephrocolic fistulae. The staghorn calculus is formed of a rapidly growing stone which tends to fill the pelvicalyceal system. Struvite-carbonate stones represent 5–10% of all stones and become supersaturated in the urine when there is infection [1, 2] as demonstrated in our case. The three major causes are chronic renal infection, trauma and calculus disease [3]. Staghorn calculi cause significant morbidity and mortality if left untreated. Therefore, typically large struvite stones must be removed. Unlike other urinary stones that commonly produce symptoms, necessitating intervention, treatment of struvite stones often occurs in patients without classic signs of nephrolithiasis. The treatment for most struvite staghorn calculi is percutaneous nephrolithotomy, followed by extracorporeal shock wave lithotripsy and/or flexible ureteroscopy and laser [2]. Occasionally, an open operation is still preferable to keyhole surgery.
Radiography is the best diagnostic modality, including abdominal and chest radiographs, barium enema, fistulography and CT scan [1, 2, 4]. Gastrointestinal and urological diseases with renal function impairment determine the extent of surgery. Nephrectomy with removal of fistulous track and the involved colon is the treatment of choice [1] in a non-functioning kidney, as in the present case. The analogy of our case to gallstone ileus is remarkable and we found only three cases of nephrointestinal fistulae with calculus impaction at the ileocecal valve reported as renal stone ileus [5–7]. Our patient had a giant calculus which passed the ileocecal valve, but the stone could not reach the rectum to be eliminated. We believe this is the first case of renal stone ileus impacted at the sigmoid ever described in literature and we named it "Lorenzi's syndrome" after the first physician who suggested this rare differential diagnosis based only on history and clinical examination.
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Figure 3. Giant renal stone view: note the renal calculus now extracted at the rectosigmoid level, which was partially resected to take this picture. Then, a sigmoidectomy was performed together with a right nephrectomy and right hemicolectomy. The descending colon was then anastomosed to the rectum (manually) and an ileocolic anastomosis with a proximal protective ileostomy (closed 7 days later) was performed.
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Received for publication January 14, 2005.
Revision received August 25, 2005.
Accepted for publication October 11, 2005.
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References
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Abstract
Case report
