Case Study - October 2009

This is a CT scan in an 84-year-old man who presented with haematemesis and was found, on upper GI endoscopy, to have a posterior duodenal ulcer with a duodenal diverticulum.

  1. What abnormality is shown on the CT scan?
  2. How can this abnormality be explained?
  3. What treatment is needed?

Reveal Answer

Open answer There is no fixed answer to this question, however your response should be similar to the one below:

  1. The CT shows gas in the renal pelvis & upper ureter floating on top of the contained urine
  2. Gas in the collecting system is due either to gas-producing organisms (especially in diabetics) or to a fistula between the urinary tract and a gas-containing viscus. In this patient, there is an uretero-duodenal fistula
  3. Management is by treating the underlying condition (the duodenal ulceration) but ureteric stenting was vrequired to speed the healing process

Fistulae between bowel and the urinary tract are most often seen in the bladder (due to colonic tumour or diverticular disease) but may also occur as a result of intestinal surgery. Fistulae into the upper tracts are very rare.

illustrative image for answer to question $n

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