Spontaneous Ureterocolic Fistula between Nonfunctioning Kidney Transplant Ureter and Colon in Setting of Diverticulitis
Description
◉ Etiology and Rarity:
• Diverticulitis-related fistula: approximately 1% of all diverticulitis cases.
• Colovesical > colovaginal fistulas are common.
• Extremely uncommon, ureterocolic fistulas have historically been brought on by TB.
• Additional causes include cancer, radiation, trauma, stones, Crohn's disease, and previous surgeries.
• Only 11 occurrences of diverticulitis-related ureterocolic fistula have been documented; none of these involve non functioning transplant ureters.
◉ Diagnostic Difficulties:
• Pneumaturia, fecaluria, bladder infection, and abdominal pain are typical symptoms.
• Absent: because of a malfunctioning, anuric transplant ureter.
• As a result, CT with contrast is used extensively for diagnosis.
• Urography and barium enema, two forms of conventional imaging, have limited use in renal failure.
◉ Summary of the Patient
• Age/Sex: female, 57 years old
• End-stage renal disease (ESRD) is the primary cause of type 1 diabetes mellitus.
◉ History of transplantation:
• In 1996, a kidney transplant failed due to persistent rejection.
• In a 2000 simultaneous kidney and pancreas transplant, the kidney failed but the pancreas was functioning.
• 2009 saw the failure of the third kidney transplant due to chronic rejection.
• Status: Hemodialysis for maintenance, anuric
• Tacrolimus 0.5 mg plus Prednisone 5 mg daily for immunosuppression
• Additional comorbidities:
• Hepatitis C chronic
• Pneumocystis pneumonia from earlier
• Prolonged anemia
• Severe peripheral vascular illness
• Amputation of the left leg due to a nonhealing wound
◉ Presenting Complaint:
• 48 hours with low-grade fever and stomach ache
• Examination results showed no peritonitis, hemodynamic stability, and localized pain in the left lower quadrant.
◉ Investigating
• CT pelvis and abdomen (with rectal contrast):
• The sigmoid colon and the left renal transplant ureter have a clear fistulous tract.
• Flexible biopsies and sigmoidoscopy:
• No indication of cancer
• Initial laboratory results showed mild leukocytosis and a chronic renal failure profile (on dialysis).
Protocol
◉ Perioperative and Surgical Course
The planned process:
End colostomy combined with sigmoid colectomy
Ureteteronephrectomy with transplant
Intraoperative splenic laceration, or splenectomy
◉ Intraoperative results:
• Verified fistula between the transplant ureter and sigmoid colon
• Nonfunctioning, necrotic kidney with pyonephrosis
• Perforation-associated diverticulosis
• Removal of the spleen damage is necessary.
• Immediately following surgery:
• ICU stay while using vasopressors
• Hemodialysis was resumed on POD 1.
• Vasopressors that POD 2 weans
• Antibiotics → Vancomycin + Micafungin + Piperacillin–tazobactam
• At 48 hours, blood cultures were negative, and antibiotics were discontinued.
• Recovery was uneventful; discharged on POD 10.
◉ Nursing Management
• Nursing Care Prior to Surgery:
• Assessment & preparation:
• Observe the dialysis schedule, baseline blood results, and vital signs.
• Check for glycemic control, illness, and electrolyte imbalance.
• If advised, make careful to prepare your bowels.
• Examine immunosuppressive treatment (see your doctor).
• Education:
• Describe the process, the repercussions of a splenectomy, and any potential stoma formation.
• psychological assistance for multiple operations and transplant failure.
• Strict aseptic care during line/dialysis access is necessary to prevent infections.
• Nutrition: control anemia and malnutrition; maximize protein intake if allowed.
◉ Nursing Responsibilities During Surgery
• Preserve sterility and precise counts.
• Help the patient position themselves to avoid pressure injuries (PAD).
• Get the vasopressors and blood products ready.
• Keep an eye out for bleeding or hypotension, which are prevalent in immunocompromised patients.
• recording of all intraoperative events, drugs, and fluids.
◉ Postoperative Nursing Care Immediate ICU Phase
• Continuous hemodynamic monitoring, including blood pressure, CVP, and urine output (although anuric).
• Titration of vasopressors according to protocol.
• Keep an eye on dialysis requirements and work with the nephrology staff.
• Observe wound drains and stoma outflow.
• Maintain oxygenation and avoid hypothermia.
• strict aseptic handling of dialysis access, central lines, and surgical sites.
• Phase of Intermediate/Post-ICU
• Pain management: employ non-nephrotoxic analgesics and assess using the proper scales.
◉ Colostomy care:
• Instruct students on fluid-electrolyte monitoring, skin protection, and pouch change.
• psychological assistance for problems with body image.
• Monitoring for infections:
• routine wound examination, CBC trends, and temperature monitoring.
• knowledge about the risk of OPSI after splenectomy.
◉ Monitoring of medications:
• levels of immunosuppressive drugs and indications of toxicity.
• If prescribed, make sure prophylaxis and antibiotic compliance are followed.
• Nutrition: check blood sugar levels in diabetic patients and promote a high-protein diet as tolerated.
• Mobilization: slow walking to avoid thrombosis (history of PAD).
Notes
FOR MORE DETAILS VISIT https://pmc.ncbi.nlm.nih.gov/articles/PMC8318765/?utm_source=chatgpt.com
