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A new case of appendicovesical fistula is reported. Usually a known cause is ulcerative colitis, morbus Crohn, malignancy of the appendix or as complication to perforated appendicitis, but in the described case there was no history of such previous illness. The only pathological finding was the presence of an abundant amount of nervous tissue in the appendix. It is concluded that a history of pneumaturia and/or recurrent urinary-tract infections must rise the suspicion of the presence of a fistula between the small or large intestine and the bladder. Peter Georg Lund, Bøgeengen 5, DK-2791 Dragør (Denmark) Introduction Fistulae between the small and large intestine and the bladder are well known as complications to diverticulitis of the sigmoid colon, carcinoma of the large intestine, morbus Crohn and ulcerative colitis. Appendicovesical fistulae are rare, presenting only few symptoms and may be overlooked for years. In the case reported here, the only pathological finding in the resected appendix was the occurrence of abundant nervous tissue, described as the presence of a benign neuroma. the sigmoid colon and a presumed fistula between the sigmoid colon and the bladder. At laparotomy a fistula was found between the apex of appendix and the bladder. The distal part of the appendix was butted, but there were no signs of previous inflammation. Appendectomy was performed, the fistula excised and the bladder was closed with 2-layer closure. The postoperative course was complicated with wound infection. Histologic examination of the appendix showed no signs of acute or chronic inflammation or malignancy, but an abundant amount of nervous tissue, e.g. a benign neuroma. By reviewing the X-ray pictures from the barium enema a thin fistula from the apex of the appendix could now be seen (fig. 1, 2). Case Report A 54-year-old male presented with a 3-year history of recurrent urinary-tract infections and during 1.5 years episodes of pneumaturia. Before admission he was treated with several antibiotics only with temporary effect. There had never been symptoms of acute appendicitis, trauma or episodes of diarrhea, bloody stools or loss of weight leading to the misdiagnosis of an D ow nl oa de d by : 54 .1 91 .4 0. 80 9 /1 6/ 20 17 6 :4 7: 31 P M inflammatory bowel disease or malignancy. At the local hospital an intravenous pyelography had shown normal conditions. At admission the patient was in good health. Laboratory tests were normal apart from pyuria and growth of Escherichia coli and Proteus mirabilis in urinary samples. Cystoscopy was performed revealing a small diverticulum of the bladder, but no signs of fistulae. Cystography was normal. Barium enema showed diverticula of Conclusion Several cases of vesicointestinal fistulae are described in the literature, often as complications to diverticulitis of the sigmoid colon, morbus Crohn, ulcerative colitis and carcinoma of the small and large intestine [5, 6], but it is very rare for the primary condition to be in the bladder. Much less common are fistulae involving the appendix [2, 8]. While fistulae between the large intestine and the bladder often give symptoms as pneumaturia and fecal-uria [2], the only constant findings in appendicovesical Appendicovesical Fistula Associated with Neuroma of the Appendix 363 Fig. 1. X-ray from barium enema showing thin fistula from the appendix. D ow nl oa de d by : 54.191.40.80-9/16/20176:47:31PM Fig. 2. X-ray from barium enema showing fistula from the apex of the appendix.ReferencesDi Paola, M.; Tockwell, W.S.: Appendico-vesical fistula due to an appendix abscess withassociated goblet cell carcinoid of the appendix. Br. J. Urol. 48: 436 (1976).Eickhoff, J.H.: Appendico-vesical fistula. Acta chir. scand. 472: 95–96(1976).Forbes, K.A.; Rose, R.J.: Appendicovesical fistula. Ann. Surg. 760: 801–805 (1964).Gross, M.; Peng, B.: Appendico-vesical fistula. J. Urol. 702: 697–698 (1969).Karamchandani, M.C.; West, C.F.: Vesicoenteric fistulas. Am. J. Surg. 147: 681–683 (1984).Naik, R.B.; Mathias, C.J.; Malik, N.: Hypokalaemic, hyperchlo-raemic, metabolic acidosis andvesical stone complicating appendico-vesical fistulae. Br. J. Urol. 52: 274–279 (1980).Rovinescu, I.: La fistule vésico-appendiculaire. J. Urol., Paris 87: 527–529 (1981).Sarr, M.G.; Fishman, E.K.; Goldman, S.M.; Siegelman, S.S.; Cameron, J.L.: Enterovesicalfistula. Surgery Gynec. Obstet. 164: 41–48 (1987).fistulae are chronic bacteriuria and recurrent urinary infections [3]. The appendicovesical fistulaerepresent 5 % of all intestinovesical fistulae and mainly occur in patients between 10 and 40years of age [2]. The etiology is often believed to be sequelae of appendicitis although 2 there areseldom any associated gastrointestinal symptoms [7]. Cases with carcinoma of the appendixwere 3 described [13]. No benign tumor has everto our knowledgebeen reported before as a possible reason to formation of an appendicovesical fistula as in ourcase. The 5 diagnosis can be provided by cystoscopy in 40% of the casesand by barium enemas in 50% [4]. Cystography 6 and intravenous pyelography give noadditional contribution to the diagnosis [8]but the use of computed 7 tomography suggests that this is the most accurate diagnostic toolavailable for demonstrating enterovesical fis8 tulae [8]. Missing the diagnosis can be seriousjust as the condition can lead to hypokalemichypochloremicmetabolic acidosis and uremia [6]; as wellpersistent enterovesical fistulae are often associated with high mortality from septicemia [5].Earlier cases have been diagnosed after the symptoms had existed For years and awareness of thepossibility of an enteric origin of chronic bacteriuria should prevent long delays in diagnosis. Downloadedby: 54.191.40.80-9/16/20176:47:31PM