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Pyeloenteric Fistula

A pyeloenteric fistula is a rare abnormal communication between the renal pelvis (pyelo-) and a segment of the gastrointestinal tract (enteric). The most commonly described subtype is the pyeloduodenal fistula, though fistulae can also extend to the colon (renocolic) or other bowel segments.[1][2] It is the upper-tract counterpart to the more familiar enterovesical fistulas of the bladder, and often arises from chronic infected obstruction or calculus disease; traumatic, iatrogenic and malignant causes also occur.[13]

For operative selection, see the Fistula Repair (All Patients) database.

See also: The Kidneys, Fistulas landing page.

Definition and Classification​

A pyeloenteric fistula falls under the broader category of uroenteric fistulae, which are classified by the urinary-tract organ of origin and the GI-tract segment involved.[1] Specific subtypes include:

  • Pyeloduodenal fistula — the most common form, almost always involving the right kidney because of its anatomic proximity to the second portion of the duodenum[2][3]
  • Renocolic / pyelocolonic fistula — communication between the kidney and colon
  • Pyeloileal or other small-bowel fistulae — exceedingly rare

Congenital fistulae are extremely rare; the vast majority are acquired.[1]

Etiology​

The fistula most commonly arises from a chronic inflammatory process originating in the kidney:[2][3]

  • Renal calculi with chronic pyelonephritis — the most frequent cause. Staghorn calculi and recurrent infections drive perirenal abscess formation that erodes into adjacent bowel[2][3][4]
  • Renal or perirenal abscess — can erode through Gerota's fascia into the duodenum or colon[5]
  • Iatrogenic / traumatic — increasingly recognized after percutaneous nephrolithotomy (PCNL) and other interventional procedures[5]
  • Malignancy — rare; reported with renal cell carcinoma and transitional cell carcinoma of the renal pelvis[6]
  • Inflammatory bowel disease — Crohn's disease can produce urinary fistulas; the cited Crohn cohort predominantly involved the bladder, not the renal pelvis[1][7]
  • Xanthogranulomatous pyelonephritis — destructive granulomatous process that can extend beyond the kidney into adjacent viscera

Pathogenesis​

The typical sequence is chronic renal infection or obstruction (most often from calculi) → perirenal inflammation and abscess → erosion through Gerota's fascia and the peritoneum → fistulization into the adjacent bowel wall. The right kidney's intimate relationship to the second portion of the duodenum explains the strong right-sided predominance of pyeloduodenal fistulae.[2][3]

Clinical Presentation​

Symptoms are nonspecific and overlap with those of the underlying renal disease, which makes the diagnosis easy to miss:

  • Fever, often recurrent or persistent
  • Flank pain and abdominal discomfort
  • Recurrent urinary tract infections or urosepsis[8]
  • Gastrointestinal symptoms — nausea, vomiting, diarrhea
  • Pneumaturia or fecaluria — more typical of enterovesical fistulae but can occur
  • Hematuria
  • Reported passage of urinary calculi per rectum — an unusual clue requiring imaging confirmation; nonspecific debris is not diagnostic
  • Anemia and weight loss in chronic cases[4]

Evaluation​

The diagnosis is frequently incidental, made during imaging or procedures performed for the underlying renal disease.[4][8]

ModalityRole
CT abdomen / pelvis with contrastIncreasingly the primary diagnostic tool; demonstrates the fistulous tract, perinephric inflammation, gas in the collecting system, and associated calculi or abscess[4][9]
Retrograde pyelographyHistorically the most effective study for demonstrating the tract[3]
Antegrade pyelography / nephrostographyContrast injection through a percutaneous nephrostomy tube can opacify the bowel and confirm the fistula[4][8]
Upper GI series / barium studiesMay show contrast entering the collecting system
FistulographyUseful for follow-up and confirmation of closure[8]
CystoscopyMore relevant for lower-tract uroenteric fistulae[7]

Management​

Management depends on the underlying etiology, the patient's overall condition, and the complexity of the fistula.[1][10]

Surgical management​

  • Nephrectomy with closure of the bowel defect is frequently used for a nonfunctioning, severely infected kidney. Assess residual renal function, source control and the possibility of renal preservation before choosing an ablative operation[2][3][4]
  • A multidisciplinary approach with urology and GI / colorectal surgery is recommended for complex cases[10]
  • For complex entero-urinary fistulae, a staged approach has been described: (1) proximal defunctioning and drainage to control sepsis, (2) nutritional optimization with TPN, and (3) delayed definitive reconstruction once the patient is stable[10]

Conservative and minimally invasive alternatives​

  • Ureteral stenting (internal or percutaneous) has been reported as an alternative to nephrectomy in selected cases by diverting urine and allowing the tract to heal[11]
  • Endoscopic clipping and ligation — successful closure of a pyeloduodenal fistula using endoclips and an endoloop has been reported in a patient unfit for surgery[8]
  • Percutaneous fulguration of the fistulous tract has been described as a nephron-sparing option[12]
  • Medical management — antibiotics, nutritional support, and treatment of the underlying inflammatory process (for example, immunosuppressants for Crohn's disease) may be attempted, though durable success without surgery is uncommon[1][7]

Key principles​

Adequate nutrition, eradication of sepsis, urinary-tract diversion, GI-tract diversion when needed, and treatment of the underlying cause anchor the management plan.[1]

Outcomes​

The historical 28-case review supported nephrectomy with duodenal closure for severely diseased kidneys.[3] A 2025 review identified 25 cases from 24 reports published in 2000–2023; more than half underwent nephrectomy. These uncontrolled reports describe management choices and cannot establish comparative superiority, a reliable recurrence rate, or a universal requirement for nephrectomy.[13] A separate 10-patient series reported successful staged treatment of mixed complex entero-urinary fistulas, not ten pyeloduodenal fistulas.[10]

See Also​

References​

1. Gill HS. "Diagnosis and Surgical Management of Uroenteric Fistula." Surg Clin North Am. 2016;96(3):583–592. doi:10.1016/j.suc.2016.02.012

2. Greene JE, Bucy JG, Wise L. "Spontaneous Pyeloduodenal and Renocolic Fistulas." South Med J. 1975;68(5):641–645. doi:10.1097/00007611-197505000-00029

3. Rodney K, Maxted WC, Pahira JJ. "Pyeloduodenal Fistula." Urology. 1983;22(5):536–539. doi:10.1016/0090-4295(83)90237-6

4. Gentile PA, Gualtieri L, Izzo S, et al. "Une Liaison Dangereuse: Spontaneous Pyeloduodenal Fistula." Dig Dis Sci. 2023;68(4):1106–1111. doi:10.1007/s10620-023-07828-1

5. Wang JH, Chiang JH, Chang T, Chen KK. "Pyeloduodenal Fistula: Report of 2 Cases." J Formos Med Assoc. 1990;89(12):1111–1114.

6. Chen CH, Cheng HL, Tong YC, Pan CC. "Spontaneous Pyeloduodenal Fistula: An Unusual Presentation in Advanced Renal Transitional Cell Carcinoma." Urology. 2002;60(2):345. doi:10.1016/s0090-4295(02)01749-1

7. Solem CA, Loftus EV, Tremaine WJ, et al. "Fistulas to the Urinary System in Crohn's Disease: Clinical Features and Outcomes." Am J Gastroenterol. 2002;97(9):2300–2305. doi:10.1111/j.1572-0241.2002.05983.x

8. Lee KN, Hwang IH, Shin MJ, et al. "Pyeloduodenal Fistula Successfully Treated by Endoscopic Ligation Without Surgical Nephrectomy: Case Report." J Korean Med Sci. 2014;29(1):141–144. doi:10.3346/jkms.2014.29.1.141

9. Yu NC, Raman SS, Patel M, Barbaric Z. "Fistulas of the Genitourinary Tract: A Radiologic Review." Radiographics. 2004;24(5):1331–1352. doi:10.1148/rg.245035219

10. Shackley DC, Brew CJ, Bryden AA, et al. "The Staged Management of Complex Entero-Urinary Fistulae." BJU Int. 2000;86(6):624–629. doi:10.1046/j.1464-410x.2000.00871.x

11. Desmond JM, Evans SE, Couch A, Morewood DJ. "Pyeloduodenal Fistulae: A Report of Two Cases and Review of the Literature." Clin Radiol. 1989;40(3):267–270. doi:10.1016/s0009-9260(89)80194-1

12. Kim SC, Weiser AC, Nadler RB. "Nephroenteric Fistula Treated With Fulguration of the Fistulous Tract." J Endourol. 2000;14(5):443–445. doi:10.1089/end.2000.14.443

13. Spanggaard K, Hvid NK, Diatchikhine M, Olesen TH, Lund L. "Pyeloduodenal Fistula: A Review of the Current Literature." Int Urol Nephrol. 2025;57(5):1357–1363. doi:10.1007/s11255-024-04327-8