Abstract
Background
Through poppy seed consumption, an enterovesical fistula was diagnosed and surgically repaired.
Summary
A 39-year-old male was incidentally found to have a multi-cystic pancreatic head lesion on magnetic resonance imaging. He underwent an endoscopic ultrasound (EUS)-guided biopsy and cyst aspiration that demonstrated findings concerning for a premalignant lesion, intraductal papillary mucinous neoplasm. The patient underwent a pylorus-sparing Whipple procedure, and pathology was consistent with acinar cell cystadenoma, an extremely rare and benign lesion of the pancreas often found in young adults. The patient presented approximately two months later with abdominal pain and was found on magnetic resonance cholangiopancreatography to have a rim-enhancing lesion adjacent and inferior to the pancreaticojejunal anastomosis concerning for an acute infectious process. The findings prompted a EUS and stent placement. Subsequently, the patient began to develop difficulties with urination with increased passage of urinary sediment, prompting Foley placement. Given concerns for possible enterovesical fistula, a poppy seed test was recommended, and within hours, the poppy seeds were noted to be draining into the Foley catheter. Computed tomography of the abdomen and pelvis confirmed iatrogenic fistula formation between the jejunum and bladder. The patient was taken to the operating room, the stent was removed, and the bowel and bladder were repaired.
Conclusion
Iatrogenic fistula formation between the urinary and gastrointestinal tract can occur. However, for patients with symptoms suggestive of an enterovesical fistula secondary to any cause, the poppy seed test is a practical, inexpensive, and accurate diagnostic tool and can help guide further evaluation with imaging and surgical management.
Key Words
enterovesical fistula; poppy seed test
Case Description
Enterovesical fistulas (EVF) usually involve the colon and occur secondary to diverticulitis, inflammatory bowel disease, intestinal malignancies, radiotherapy, or trauma in developed countries.1‒4 Diagnosis of EVF can often be challenging. Here, we report the first case of an EVF due to endoscopic ultrasound-guided (EUS) drainage and Axios™ transjejunal stent placement for a symptomatic peripancreatic fluid collection, diagnosed initially by a simple poppy seed test.
A 39-year-old Caucasian male with a history of hemochromatosis was incidentally found to have a multi-cystic pancreatic head lesion (2.3 × 5.5 cm) on magnetic resonance imaging (MRI) during a workup for asymptomatic microscopic hematuria. He underwent an esophagogastroduedenoscopy (EGD), which localized a thin-walled multi-cystic lesion in the pancreatic head consistent with cross-sectional imaging. The appearance was suggestive of serous cystadenoma. However, further workup showed inconsistent results. Endoscopic ultrasound (EUS)-guided biopsy and cyst aspiration showed a cytology of Bethesda III with degenerated glandular cells and mucinous material, a finding concerning for a premalignant lesion, intraductal papillary mucinous neoplasm (IPMN), rather than serous cystadenoma. Cystic fluid analysis showed low carcinoembryonic antigen of 92 and relatively high amylase of 1672, values which were not typical of either IPMN or serous cystadenoma. KRAS mutation was negative. After a thorough discussion with the patient, surgical resection was recommended to rule out malignancy.
The patient underwent a pylorus-sparing Whipple procedure. Pathology was consistent with acinar cell cystadenoma (ACA), also known as acinar cystic transformation, an extremely rare and benign pancreatic lesion often found in young adults.5 The initial postoperative course was uneventful, and the patient was discharged on postoperative day (POD) 5. Approximately two months later, the patient was readmitted for worsening abdominal pain and fevers in the setting of elevated liver function tests. Magnetic resonance cholangiopancreatography (MRCP) demonstrated a rim-enhancing lesion adjacent and inferior to the pancreaticojejunal anastomosis concerning for an acute infectious process (i.e., infected peripancreatic fluid collection, perihepatic/peripancreatic abscess). The finding prompted an EUS, which identified a single anechoic lesion distal to the gastrojejunostomy anastomosis. The fluid was aspirated and noted to be clear yellow. No overt infection was noted, and the fluid culture was found to be sterile. Thus, the decision was made to marsupialize the presumed peri-pancreatic cyst and create a cystojejunostomy with an Axios™ stent to prevent recurrence of the cyst.
The patient developed acute urinary retention (AUR) after stent placement, which was initially managed with straight catheterization; however, he had persistently elevated post-void residuals. He ultimately elected for Foley catheter placement. At this point, urology was consulted for recurrent AUR and Foley management. The patient's urologic history was notable for remote hematuria with negative workup, but otherwise no history of lower urinary tract symptoms. The patient reported irritative voiding symptoms following stent placement and the passage of particulate material in his urine. He denied gross hematuria; however, he had noted intermittent green urine. Recent urine culture was negative. No causal medications or other overt etiologies were identified. Given concerns for possible EVF, a poppy seed test was recommended (Kwon et al.). The patient ingested poppy seeds mixed with a thin liquid. Within six hours, the poppy seeds were noted to be draining into the Foley catheter (Figure 1).
Figure 1. Poppy Seeds Seen in the Foley Bag 6 Hours Following Ingestion. Published with Permission
