Uterocutaneous Fistula: A Complication of Ruptured Appendix and Crohn's Disease During Pregnancy

Abstract

Abstract

Background: Appendicitis is the most common nonobstetrical surgical problem in pregnancy. The incidence of the disorder ranges from 1/1312 to 1/2000 pregnancy episodes. The diagnosis of appendicitis is made on the basis of clinical signs and symptoms, laboratory data, and noninvasive imaging. A major risk for acute appendicitis in pregnancy is perforation, abscess formation, and peritonitis. The management of ruptured appendix has changed recently for nonpregnant patients (i.e., nonsurgical initial treatment). Experience with this contemporary therapy has been quite limited during pregnancy. Uterocutaneous fistula is a rare entity with serious consequences for the afflicted woman. Case: A 19-year-old primigravida at 23 weeks of gestation presented with right lower abdominal pain, nausea, vomiting, and elevated white blood cell count. A computed tomography (CT) scan revealed a 4.2 × 5.1-cm mass in the right lower abdomen consistent with focal phlegmon and periappendiceal abscess. General surgical consultation was obtained, and it was decided based on the surgeon's opinion to treat this patient with antibiotics and to attempt CT-guided percutaneous drainage of the abscess. Several drainage procedures were performed. The patient's symptoms improved over the next 5 days but her temperature remained elevated and her white blood cell count likewise was elevated. The patient went into labor at 27 weeks and because of ongoing abscess formation and suspected chronominitis, a classical cesarean section (C-section) was done. The surgeons also scrubbed in. The latter opened an old abscess cavity located between the anterior abdominal wall and the uterus. They additionally performed extensive adhesiolysis but did not remove the appendix. Postoperatively, the patient experienced several bouts of abscess formation that were drained with CT guidance. She was readmitted postpartum for recurrent abscess formation. Six (6) weeks following her last admission, the patient was discharged with uterocutaneous fistula. Subsequently, during the workup aimed at excising the fistulous tract and repairing the uterus, a CT scan revealed an additional enteric cutaneous fistula and ileal scar formation compatible with a diagnosis of Crohn's disease. Conclusions: This case demonstrates recurrent abscess formation following perforated appendix. A classic C-section was performed at 27 weeks for valid indications. However, the surgeons failed to perform an appendectomy or explore the ileum or cecum. Subsequently, uterocutaneous and enterocutaneous fistulas were diagnosed together with ileal narrowing, leading to the postpartum diagnosis of Crohn's disease. (J GYNECOL SURG 26:163)