Friday, September 26, 2008

Unwelcome "Tiny Bubbles"

So, the big debate is on right now, and as I would rather not start blasting my TV with an over/under 12 gauge, I thought I would do a little random typing. About poop. And urine. Sort of what has been being flung around with glee during this political season.


As I may have stated before, I don't really go in for much of the esoteric when reading surgical journals --- just give me a straightforward presentation, preferably of a condition I am likely to encounter, and add something to the available data at my disposal. Here is a nice example -- Management of the Bladder During Surgical Treatment of Enterovesical Fistulas From Benign Disease. I know, the title alone is enough to drive the average person --- let alone an internist --- to sleep without a hot toddy, but indulge me.

An enterovesical fistula is basically an unnatural communication between a piece of the intestine and the bladder. EEEEWW! That's right, it allows poop and gas to pass from the inside of the bowel to the bladder. Its presence is heralded by recurring Oh-My-God urinary tract infections and somehing we physicians euphemistically refer to as "pneumaturia." Yeah. Google that one and then squirm a little bit, why dontcha. Let's just say that while urinating it makes one sound like a little kid blowing bubbles in the bathtub. "Tiny Bubbles" they may be, but certainly not the kind Don Ho sang about.

Why on God's Al Gore's green earth would somebody develop an enterovesical fistula? Three main reasons: cancer, inflammatory bowel disease, and diverticular disease. Since this article is about non-malignant causes, let's deal with cancer first and then ignore it from here on out --- basically, a tumor (usually colon) can erode from one hollow body part into another, setting up an abnormal communication.

Inflammatory bowel disease is another matter altogether. This name encompasses two conditions, Crohn's disease and ulcerative colitis, only one of which is associated with enterovesical fistulas ---- Crohn's, which is described in great detail here. Suffice it to say that the intense inflammation in Crohn's can result in abnormal communication between a loop of bowel and another loop of bowel, the ureter, the skin, the bladder....... Not pleasant, and in some patients it is a true scourge.

Diverticular disease of the colon is quite common, and can result in enterovesical fistula development due to episodes of diverticulitis (Lord help me, but I cannot type that word without thinking of Joe Piscopo and Robin Duke - "But we've got di-ver-tic-u-LI-tis!"). This is the most common cause of an enterovesical fistula in my practice, and I see about 1-2 cases a year where there is bladder involvement with diverticular disease.

The mainstay of treatment for an enterovesical fistula, everyone agrees, is to "remove the offending organ." Simply put, take out the piece of intestine causing all of the aggravation. The bladder is an innocent bystander here.....but, you know, when you take out the loop of bad bowel, there is a hole left there in the bladder. What is the upstanding surgeon to do with it?

Well, the bladder is part of a fairly low pressure system --- unless you really, really have to go. Drink a little coffee, and soon urine trickles from the kidneys down a pair of thin tubes called ureters into a reservoir that will expand (up to a point, depending on one's tolerance) to accomodate it. This is not like the arterial system, where blood is forcibly pumped through muscular arteries. So, some would say just leave a catheter in the bladder to keep it decompressed for a while and let things scar down. We do this in trauma settings when patients have a ruptured bladder..... but not when the bladder has ruptured into the free abdominal cavity. Others, including me, don't really like to see a hole, well, just left there for everybody to see! And so, my habit has been to close it with a few absorbable sutures, and leave a catheter in for about a week. It's an approach that has always worked, so why mess with it, right?

Well, these nice folks noticed that there was this minor discrepancy in practice patterns, and decided to retrospectively look at the outcomes of 74 patients over an eight year span. Basically, they found that regardless of the approach, as long as there is no huge defect in the bladder that mandated closure, simply leaving a Foley catheter in place for a week is all that is required. Simple, no muss, no fuss.
Oh well, I've wasted enough time, and hopefully have saved my TV from destruction again tonight. But there are two more of these debates, so SWIMBO will have to hide the shells.