A 76‐year‐old woman presented with a 1‐day history of bloody bowel movements and syncope. She also noted weakness and lower abdominal pain but denied nausea or vomiting. She had been constipated for the past 10 days, until her recent maroon and bright red bowel movements. She has type 2 diabetes, hypertension, congestive heart failure, and renal cell carcinoma. Two weeks earlier, she had undergone a palliative, CT‐guided percutaneous cryoablation to a 4‐cm lumor on her left kidney. On admission, she was afebrile and her vital signs were normal. Her heart, lung and neurologic examinations were normal. She was tender to deep palpation in her left lower abdomen. She had bright red blood on rectal exam. Hemoglobin was 9.1 on admission; it dropped 6 hours later to 7.3. The remainder of her hematologic and metabolic blood work was normal. Her urinalysis had glucose > 1000 and trace mucous, but no fecaluria. ACT scan revealed a 7 × 7 × 7 cm lesion within the lower pole of the left kidney, representing the prior cryoablation, along with inflammatory changes, oral conlrast, and foci of air The small and large bowel was in close association with this area and likely represented a bowel fistula.
Although the most common causes of hematochezia are malignancy, hemorrhoids, diverticulosis, ischemic colitis, and angiodysplasia, it is important to elicit a detailed surgical history to ensure that postsurgical complications are not present. In particular, the hospitalist must be aware of the complications of percutaneous cryoablation. as this has become an increasingly common intervention for palliative treatment of intraperitoneal malignancies. Although the colon is typically hydrodissected during cryoablation to reduce the risk of injury to the descending colon, it is possible to inadvertently puncture the bowel with an applicator or extension of the ablation zone. Perforation may then be followed by fistula and abscess formation. Although fistulography is instrumental in diagnosing some types of fistulas, contrast‐based CT remains the single most useful diagnostic modal ity for diagnosing colorenal fistula. Although colonoscopy is usually indicated in lower Gl bleeding, there is no evidence to support this procedure for management of colorenal fistulas.
Conservative management should be considered in patients with a stable clinical status, normal kidney function, and previous success with ureteral stenting to close fistulas. When conservative managemenl is not an option or the fislula is complex, surgery is the mainstay of treatment. Indications for surgery include intestinal obstruction, bleeding, sepsis, or renal failure and consist of partial or total nephrectomy and partial bowel resection. Because of our patient's comorbidities and acute lower Gl bleed, surgical exploration was performed to treat her lower Gl bleed
J. Wysocki, none.