A 74-yr-old woman was transferred to our hospital from a local clinic because of generalized weakness and high fever with chills on January 17, 2013. She had been complaining of abdominal discomfort. She had no underlying illness such as diabetes mellitus, hypertension, hepatitis, or tuberculosis. Her family history and social history were non-specific. For 15 days, prior to admission, she received conservative treatment for herpes zoster infection on the anterior chest without an anti-viral agent.
At the time of admission, her body temperature was 37.8C and blood pressure was 110/80 mmHg. Her heart rate was 112 beats per minute being faster than normal with sinus rhythm on ECG. Laboratory examination revealed pyuria, isomorphic hematuria, positive leukoesterase and bacteria on urinalysis. Systemic leukocytosis with a predominance of neutrophils (white blood cell count of 21,650/microL) and a high C-reactive protein level of 35.63 mg/dL were shown in the blood test. Blood urea nitrogen and serum creatinine level had risen to 69.4 mg/dL and 4.28 mg/dL, respectively, from normal values at baseline. Serum potassium was 6.0 mM/L, and coagulation test results were lengthened to a PT INR of 1.4 and an aPTT time of 70.2 sec.
Physical examination was otherwise unremarkable except diffuse abdominal tenderness. Through laboratory tests and physical examinations, the patient was suspicious of urinary tract infection combined with acute kidney injury. Next, a computed tomogram (CT) was checked and it revealed hydronephrosis with upper ureteral stones and multiple ill-defined hypodense lesions suggestive of acute pyelonephritis in both kidneys.
Percutaneous nephrostomy (PCN) was performed in both kidneys, and during this procedure, right PDF was visualized. Pyelography revealed a fistula to the descending part of the duodenum (Fig. 1). We prescribed total parenteral nutrition and intravenous antibiotics and planned surgery for PDF. However she was too old and was considered to be emaciated to tolerate nephrectomy and general anesthesia. Also, the surgeon was not able to find out the exact leakage site on CT. Therefore, gastroendoscopy was decided to avoid surgery. The gastroenterologist discovered PDF in the duodenal second portion and clipped the lesion 4 times (Fig. 2). After an appropriate course of parenteral antibiotics therapy with the clipping procedure, her temperature and white blood cell count returned to normal, and her urine culture grew Klebsiella pneumoniae which showed all sense to the antibiotics. The patient, however, had to undergo one more endoscopic procedure after 1 week because her follow-up fistulography revealed that there was still a communication between the pelvis and duodenum, but the amount of leakage was significantly reduced. The gastroenterologist ligated the fistula site with a detachable snare which is an elliptically shaped nylon loop used to tighten around the fistula site. This device has recently been used for closure of gastrointestinal fistula followed by application of a clip in the field of gastroenterology. Follow-up fistulography was performed after 1 week, and we were able to confirm there was no more leakage (Fig. 1). Her blood urea nitrogen and serum creatinine levels recovered to normal showing 10.7 mg/dL and 0.86 mg/dL, respectively. Her urine culture was returned to negative finding. She was discharged after confirmation of appropriate oral intake on admission day 30. The urologist removed PCN in the outpatient clinic, and then finally treated her stones by extracorporeal shockwave lithotripsy.