A 48-year-old otherwise healthy woman with recurrent urinary tract infections presented to the emergency department with 1 month of fever and flank tenderness. Three months prior, she was diagnosed with a 3-cm right staghorn stone; interventions were postponed due to the SARS-CoV-2 pandemic. Percutaneous nephrolithotomy was attempted: unexpectedly, dye injected into the ureter filled the bowel on fluoroscopy, suggesting a renal-enteric fistula (a). Computed tomography demonstrated xanthogranulomatous pyelonephritis (XGP), a rare chronic pyelonephritis, with perinephric stranding abutting a thickened duodenum. Endoscopy was performed to plan for intervention, revealing a fistulous opening in the second segment of the duodenum (b). Pyeloduodenal fistula is an extremely rare, late-presenting sequela of XGP (1). Definitive management traditionally involves primary surgical fistula closure with nephrectomy (2). Endoscopy facilitates fistula localization; furthermore, with the advent of Over-the-Scope-Clips (OTSC) for fistula closure, endoscopic approaches should be considered first as a safe, feasible alternative to surgery. There are two reported cases of pyeloduodenal fistula closure using OTSC (3,4). Endoscopic intervention was considered here; however, given the patient’s significant renal involvement, she underwent nephrectomy with concurrent surgical clipping of the fistulous tract. Pathology revealed abscesses and necrosis infiltrating the renal parenchyma. Post-operatively, she required parenteral antibiotics and remained well 6 months post-discharge.
Contributor Information
Grace Wang, Department of Gastroenterology and Hepatology, University of Toronto, Toronto, Canada.
Parul Tandon, Department of Gastroenterology and Hepatology, University of Toronto, Toronto, Canada.
Christopher Wayne Teshima, Department of Gastroenterology and Hepatology, University of Toronto, Toronto, Canada.
Informed Consent
Informed consent was obtained from the patient for the publication of their information and imaging without any identifying information.
Authors’ Contributions
All authors have made substantial contributions to all of the following (1) conception and design, (2) drafting and revising the text, and (3) final approval of the version to be submitted.
Conflict of Interest
The authors have no personal or financial conflicts of interest to disclose.
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