Stesura Seveso 383Archivio Italiano di Urologia e Andrologia 2014; 86, 4 CAS E REPORT Enterovesical fistula and acute pyelonephritis in renal transplantation. Role of ultrasound Antonio De Pascalis, Alessandro D’Amelio Nephrology and Dialysis Unit, V Fazzi Hospital, Lecce, Italy. The enterovesical fistula is a communi- cation between the urinary tract and the colon and is a rare complication of various inflamma- tory and cancer diseases. The most frequent cause is rep- resented by diverticulitis of the sigmoid colon and less frequently from Crohn's disease, tumors of the colon and bladder, trauma, radiation therapy and appendicitis. In this report we describe the occurrence of an enterovesical fistula in a patient with renal allograft from a cadaveric donor, which onsetted with signs of acute pyelonephritis and pneumaturia due to diverticulitis of the sigmoid colon, clinically silent. The ultrasound in the diagnosis of enterovesical fistula, yet with a minor role compared to computed tomography (CT), is fundamental being always the first level examination. KEY WORDS: Fistula; Bladder; Pyelonephritis. Submitted 3 October 2014; Accepted 31 October 2014 Summary No conflict of interest declared. the presence of a fistula between the sigmoid colon and the left side wall of the bladder, associated with numer- ous diverticula of the colon (Figure 2). After starting antibiotic therapy with ciprofloxacin and teicoplanin we assisted to a dramatic improvement of the clinical pic- ture. Subsequentely patient underwent surgical sig- moidectomy and bladder repair. DISCUSSION Enterovesical fistulas account for over 80% of fistulas between digestive and urinary tract and, the most fre- quent between the bladder and sigmoid colon. Diverticulitis of the colon is the most frequent cause of fistula with the bladder, followed by Crohn's disease and colon cancers (1). In the case reported the patient had complicated diverticulitis of the colon, with a very few symptoms (the patient reported only alternating diar- rhea and constipation) evidently because of steroid therapy. However, the clinical picture dominating the majority of patients with enterovesical fistula, as report- ed in the literature and as moreover observed in our case, are the urinary symptoms (fever, dysuria, or even pneumaturia and fecaluria) (2). The occurrence of pneumaturia is a highly specific sign of a communication between the intestine and bladder, reported in 60-85% of cases described in the literature (3). In the literature there are few reports about the ultra- sound scan for pneumaturia and then about the diagno- sis of enterovescical fistula by ultrasound examination. The typical signs described are: the presence of the so- called echogenic beak, i.e. an area of hyperechoic beak, between the bladder and adjacent bowel, without solu- tion of continuity; the passage of air and echogenic mate- rial in the urine, after the abdominal compression; the presence of irregular hyperechoic foci with shadow cone back (4). The most sensitive and specific test is, of course, CT which allows you to directly highlight the presence of the fistula, the cause that generated it and its associated complications (5). Less sensitive and specific and therefore not indicated, is the intravenous urography. Cystoscopy is obviously highly sensitive and specific and is often performed as an examination of the level before the CT in suspected enteric fistula with bladder. DOI: 10.4081/aiua.2014.4.383 Presented at 19th National Congress S IEUN, Fermo 2014 CASE REPORT A 64 years old male, with a kidney transplantation from cadaveric donor for about 5 years and treated with pred- nisone, tacrolimus and mycophenolate, presented to the emergency room with signs and symptoms suggestive of urinary sepsis (fever, hypotension, dysuria, pain in the right iliac fossa, where the graft was allocated). Laboratory tests showed: mild worsening of renal func- tion (creatinine 2.4 mg/dL), neutrophilic leukocytosis (GB 14.440/ml with 91% neutrophils), elevated inflam- matory markers (ESR 120, CRP 153 mg/dL, procalci- tonin 5 mg/L), urine examination revealed leukocyturia, hematuria, bacteriuria. The patient reported that he had noticed at home the issue of foamy urine. An ultrasound of the kidney and urinary tract showed a transplanted kidney of globular shape with multiple hypoechoic areas suggestive for hydroureteronephrosis grade II, presence of intrapyelic hyperechogenic material and a diffusely thickened blad- der (Figure 1); color Doppler evaluation showed an increased intraparenchymal Doppler RI (0.84). We there- fore decided to perform a computed tomography (CT) scan which confirmed the signs of acute pyelonephritis of the graft, showing also the presence of hydro-air level and Archivio Italiano di Urologia e Andrologia 2014; 86, 4 A. De Pascalis, A. D’Amelio 384 In conclusion, we reported a case, one of the few in the literature, of enterovesical fistula secondary to diverticulitis of the colon in a kidney transplanted patient. Concomitant immunosuppressive therapy and steroids in particular, has probably masked the clinical picture until the onset of acute graft pyelonephritis. The ultrasound in the diagnosis of enterovesical fis- tula, yet with a minor role compared to CT, is fun- damental being always the first level examination because of its non-invasiveness, repeatability and low cost, and it can provide guidelines that address the diagnosis. BIBLIOGRAPHY 1. Krco MJ, Jacobs SC, Malangoni MA, Lawson RK. Colovescical fistulas. Urology. 1984; 23:340-342. 2. VesaLlane´s J, Llado Carbonell C, Valverde Sintas J, Bielsa Gali O. Fistulas vesico-sigmoideas. Arch EspUrol. 1991; 44:1133-1138. 3. Kirsh GM, Hampel N, Shuck JM, Resnick MI. Diagnosis and management of vesicoenteric fistulas. Surg Gynecol Obstet. 1991; 173:91-97. 4. Long MA, Boultbee JE. Case report: the transabdominal ultrasound appearances of a colovesical fistula. Br J Radiol. 1993; 66:465-467. 5. Jarrett TW, Vaughan ED. Accuracy of computerized tomog- raphy in the diagnosis of colovesical fistula secondary to diver- ticular disease. J Urol. 1995; 153:44-46. Figure 1. US. Hyperechoic material in pelvis with acoustic shadowing and thickened ureteral wall. Figure 2. CT. Air-urine level in the bladder. Correspondence Antonio De Pascalis, MD (Corresponding Author) depascalis.a@libero.it Alessandro D’Amelio, MD Nephrology and Dialysis Unit, V Fazzi Hospital Piazza Muratore 1 - 73100 Lecce, Italy