Calyceal Cutaneous Fistula Connor Deal February 2013

HPI: 73 year old female with recurrent right flank abscess s/p drainage (3/2012, 9/2012) who presents with further work- up of recurrent abscess – suspicion for enterocutaneous fistula. No fevers/chills. PMH: HTN, CKD, Nephrolithiasis, DVT (2/2012), DM PSH: Kidney stone removal (1969), Right flank abscess drainage (3/2012, 9/2012), av fistula placement (7/2012), ivc filter (2/2012) PE: Vitals: WNL; Gen:AOx3; Back:Guaze/Tegaderm over R- flank abscess with milky/yellowish purulent drainage. Slightly tender. Labs: BUN: 55; Bicarb: 15; Creat: 4.16; WBC History

We know there is an abscess. Is there a fistula? DDx

ACR Criteria for suspected abscess

TIMELINE March 2012 drain R flank abscess 2/4/2013 Admission 2/5/ :20pm Fluoroscopy 2/5/2013 2:30pm Ultrasound 2/5/2013 9:14pm CT Abdomen 2/6/2013 IR Drainage Sept 2012 drain R flank abscess

Fluoro Sinogram Fistulogram GI tract only -Prior to full injection of contrast What is this?

Fluoro Sinogram Fistulogram GI tract only

CT Abdomen W/O IV contrast – Coronal View

CT Abdomen W/O IV contrast – Saggital View Air bubble?

IR drain placed by IR – 1 month duration flagyl and levaquin – for diverticulitis Followup Future of kidney? Outcome

65 yo female with right flank pain found to have complete right staghorn calculus with nephrocutaneous fistula. Fistula found by retrograde pyelogram which also confirmed the need for complete right nephrectomy. Case Report (1990)

Figure 3: Right retrograde pyelogram shows the pelvic calcification outside the ureter and a fistulous tract between the renal pelvis and the skin.

Charles JC. Nephrocutaneous fistula. J Natl Med Assoc. 1990;82 (8): PMID PMC Reference