A 50-year-old woman with a history of hypothyroidism treated.
One month of evolution of poorly defined hypogastric pain without dysuria and mild weight loss.
One week prior to hospitalization in another center, the pain became intense, stabbing, non-irradiated, accompanied by dysuria at the end of the hospital stay, without fever, reason why she was hospitalized.
Upon admission she was afflicted, hemodynamically stable, with mild hypogastric pain.
The admission exams showed a hematocrit of 46%, 5,500 leukocytes/mm3, without deviation to the left, urine sediment with 4 to 6 leukocytes per field, 40 to 45 leukocytes without bacteria.
Abdominal ultrasound showed free intra-abdominal fluid, which was confirmed by contrasted axial tomography (CAT).
An exploratory laparotomy was indicated, so the patient decides to consult in our medical service.
As a remote history she had two pregnancies, with a cesarean delivery and a vaginal forceps delivery 12 years before, during which she suffered a bladder perforation that was repaired.
On admission, the patient was in good general condition, with mild sensitivity in hypogastrium and with displaceable morningness, normal air-fluid sounds.
Admission tests: hematocrit of 51%, 8,000 leukocytes/mm3 without left shift, ESR of 6, CRP of 2.1 mg/dl, NU of 36, creatinine of 2,16 mg/dl normal liver cholesterol profile 4, 280 mg/dl.
Urine sediment showed parasites 30 to 35 per field, pyocytes 4 to 6 per field, regular amount of cocacea and bacilli, and scarce amount of cells in the transitional epithelium.
Treatment was initiated with cefazolin 1 g every 8 h.
A diagnostic paracentesis was performed, which gave exit to a clear liquid. The suprapathic pathology was interpreted with 10 leukocytes, 74% of mononuclear cells, 0.6 gr/dl of proteins and 0.3 gr/dl portal hypertension albumin gradient.
The patient was allowed to fast, a urinary catheter was installed and 3,000 cm3 of intravenous volume was delivered.
Twenty-four-hour diuresis was only 700 cm3 and increased abdominal dyspnoea, with a 2-k weight gain.
The presence of a non-inflammatory ascites, with very low proteins and albumin in the liquid, and having ruled out portal hypertension, in a patient with high creatinine, urine was due to ascites.
A defecating paracentesis was carried out for 3⁄4n with measurement of nitrogen and creatinine in the liquid, which were 43 mg/dl and 10 mg/dl, respectively.
Ascites and serum creatinine were 15 mg/dl and 1.09 mg/dl, respectively, on the following day.
Cystoscopy showed v-peritoneal fistula and presence of suture remnants in the fistula margins.
With the diagnosis of v-peritoneal fistula without defined cause, she underwent an exploratory laparotomy, which showed moderate amount of clear and transparent free fluid, healthy abdominal organs, uterus and annexes without lesions.
A stellate orifice measuring 1.5 cm in diameter, anfractuous, was confirmed in the bladder dome, from which sterile serum flowed into the peritoneal cavity, to the bladder catheter.
There was no omentum or wings attached to the bladder.
The fistula was in a very thin area of bladder wall, where there is no detrusor, which protruded into the cavity.
The weakened bladder area was resected until a detrusor of healthy appearance was found, performing a cystorrhaphy.
Peritoneal drainage was left by contracture and the bladder was drained with a wide-lumen Foley catheter (Fr.
24).
He had a favorable postoperative evolution, recovering intestinal transit, without hematuria or elements suggestive of infection.
The bladder catheter was maintained for one week. Antibiotic treatment was completed and a negative urine culture and biopsy showed a healthy but thin bladder mucosa in relation to the diverticulum area.
