p-ISSN: 2980-4302
e-ISSN: 2980-4310
Vol.
2 No. 6 June 2023
COLOUTERINE
FISTULA CAUSED BY INTRAUTERINE DEVICE MIGRATION: A CASE REPORT
Dwicha Rahmawansa
Siswardana, Grady Adrian Dwi Kendra
Digestive
Surgery Division, Medical Faculty, Brawijaya University, Indonesia
Email: dwicha83@yahoo.com, gradyadrian@gmail.com
Abstract
Intrauterine
device (IUD) is simple and long-term medical device contraception. The IUD is a
one of safety long duration contraception with several systemic side effects.
But it can also cause morbidity by migration into another organ. IUD migration
is a one of rare complication. We present a 28-year-old woman came to surgery
department presented with hematoschezia when menstrual period since one month ago. Physical examiation showed
hemodynamically stable and no abnormality. According to pelvic x-ray examination
showed corpus allienum of IUD projected in pelvic cavum as high as foramen
III-IV sacralis anterior. Patient also examined for CT-Scan that showed corpus
allienum 1000-2000 HU density (T-shape IUD) in uteri cavum penetrate right
posterolateral wall of uteri into sigmoid colon as high as S3 vertebrae
followed by pneumoperitoneum of Douglas cavum. Colonoscopy showed rectal
bleeding due to corpus allienum of expulsion of IUD. IUD extraction may lead to
difficulties using colonoscopy so she planned to laparoscopic procedure.
Possible laparoscopic options for IUDs embedded in the bowel include device
extraction and intracorporeal suturing, or resection of the affected segment
with primary anastomosis. She underwent a laparoscopic surgery to IUD extraction,
adhesiolisis, and colouterine fistula repair.
Keywords: Colouterine
Fistula; intrauterine device; migration;
INTRODUCTION
Intrauterine
devices (IUDs) are the most well-known, long-term and modern method of
contraception (Mona et al., 2020). The IUD is a
a long duration contraception with few systemic side effects, but it can cause
significant morbidity following migration into another organs. IUD migration
can cause several disease such as obstruction, perforation, ischemia,
mesenteric injury, strictures and fistulae (Weerasekera et al., 2014). The incidence
of uterine perforation by IUD is reported to be between 1.3 and 1.6 per 1000
insertions (Akpınar & Altun, 2014). The
proportion of IUD intestinal penetration in large intestine especially sigmoid
colon were 40.4% followed by small intestine (21.3%), and rectum (21.3%) (Aliukonis et al., 2020).
Retrieval of IUDs is commonly done using colonoscopic
and laparoscopic techniques (Weerasekera et al., 2014). Colonoscopy
is effective when the device is in the lumen or inner part of the wall, but it
may be challenging if the device is partly embedded in adjacent structures,
such as a complex lesion like a colo-colic fistula. In such cases, a
laparoscopic procedure is preferred for IUD extraction. Laparoscopic options
include device extraction and intracorporeal suturing, or resection of the
affected segment with primary anastomosis. According to Maggiori & Panis, (2013) Laparoscopic
approaches have several advantages such as reduced tissue trauma, lower
postoperative pain, early return to function, and a lower risk of
intra-abdominal adhesions compared to other methods(M. Huh et al., 2018; B. F. Santos et al., 2017).
We report the case of Indonesian woman who suffer
hematocezia when menstrual period which caused by intrauterine device migration
complicated a colouterine fistula and treated with laparoscopic surgery.
RESEARCH METHODS
A 28-year-old woman came to surgey department at
19/11/2022 and presented with hematocezia when menstrual period since one month ago. Hematocezia worsen over time. Patient
didn’t have comorbidity such as diabetes melitus, hypertension, vardiovascular
disease, hematology disease, astma, and chronic cough. Two monts ago, patiens
suffer vaginal discharge and has history of sectio caesarean in 2017.
Physical
examination showed moderate sick with GCS E4V5M6. Vital sign showed blood
pressure 110/70 mmHg, heart rate 80x/m, respiration rate 20x/m, SpO2:
99% (Alghadir et al., 2014). General
examination heat to toe showed no abnormalities. Vaginal touche showed no
fluxus, flour, closed porti, normal Corpus Uteri Ante Fleksi (CUAF), appendix
D/S showed no mass and tenderness.
Laboratorium
examination showed Hb : 12,2 mg/dL, Leucocyte : 8.790
cells/µL, Thrombocyte : 275.000 cells/µL, PT/APTT : 10,3 second / 29,10 second.
Billirubin Total/Direct/Indirect : 0,22mg/dL / 0,08mg/dL
/ 0,14 mg/dL , Albumin : 4,90 g/dL. GDS : 96 mg/dL,
Ureum / Creatinine : 8,4 mg/dL / 0,59 mg/dL. Electrolyte Na :
141 mEq/L, K 3,43 mEq/L, Cl 112 mEq/L. Negative antigen swab of SARS-CoV-2.
The
colonoscopy with indications of rectal bleeding showed IUD expulsion. Pelvic
anteroposterior / lateral x-ray examination showed corpus allienum of IUD
projected in pelvic cavum as high as foramen III-IV sacralis anterior (Figure
1). Colonoscopy showed rectal bleeding due to corpus allienum of expulsion of IUD,
internal hemorrhoid and non specific colitis (Figure
2). Patient also examined for CT-Scan and showed CT Scan examination showed
corpus allienum 1000-2000 HU density (T-shape IUD) in uteri cavum penetrate
right posterolateral wall of uteri into sigmoid colon as high as S3 vertebrae
followed by pneumoperitoneum of Douglas cavum. There was no free fluid level in
intraabdomen (Figure 4). She planned to laparoscopy and extraction of IUD in
operating room by Digestive Surgeon join with Obstretician.
Laparoscopic
surgery showed some finding, first omentum adhesion in right inferior anterior
abdominal wall. Second, adhesion of sigmoid colon to right postior lateral
uterus. Third, tail of IUD penetrates to sigmoid colon and T of IUD still in
uterus (Figure 4). So, patient conducted adhesiolisis and opening the
colouterine fistula. IUD was extrated from sigmoid colon and sutured the defect
in the sigmoid colon.
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Figure 1.
Pelvic anteroposterior and lateral x-ray examination |
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Figure 2. Colonoscopic Examination |
Colonoscopic
evaluation showed that hemorrhoid interna in anal segment, active bleeding and
blood clot 50 cm in rectum segment. Corpus alienum like a metal 20cm near from
anal segment. Forcep biopsy examination showed hard and bleeding in near corpus
alienum. Colon descenden, tranversum, ascenden, caecum, and illeum has no
abnormality.
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Figure 4.
Laparoscopic surgery |
|
.
RESULT AND DISCUSSION
We present our case
because it is extremely rare. Almost two-thirds of migrating IUD is generally
located inside the uterine cavity. However, according to the study made by
Cetinkaya et al. most common extra-uterine location of lost IUDs is around the
uterosacral ligaments (Cetinkaya et al., 2011).
Patient presenting
hematoschezia when menstrual period. The symtomps of IUD migration consist of
acute abdominal pain, irregular vaginal bleeding, or bloody stool occurs. The ultrasound examination can assist in
distinguishing ectopic IUDs from other causes (Zhou et al., 2018). Other possible pathological processes that could involve a concurrent
uterine and bowel perforation could be trauma, neoplasm, or even aggressive
infectious disorder (Carroll et al., 2022).
In this case,
colonoscopy used to identify the possible cause of rectal bleeding.
Colonoscopic and laparoscopic techniques commonly being used for retrieval of
IUDs. Colonoscopy is useful when the device in the lumen or embedded in the
inner part of the wall. Colonoscopic retrieval may lead to difficulties if the
device is partly embedded in adjacent structures. A complex lesion such as a
colo-colic fistula would be extremely difficult to identify at colonoscopy (J. M. Huh et al., 2018).
In this case, the
IUD extraction may lead to difficulties using colonoscopy so she planned to
laparoscopic procedure (Banerjee et al., 2012). Possible laparoscopic options for IUDs embedded in the bowel include
device extraction and intracorporeal suturing, or resection of the affected
segment with primary anastomosis. The advantages of laparoscopic approaches
include : reduced tissue trauma, lower postoperative pain, and early return to
function and lower risk of intra-abdominal adhesions (A. P. Santos et al., 2017).
CONCLUSION
Although
rare, the migration of intrauterine devices to the colon can be a serious
complication. The management of such cases can be a challenging decision for
both the patient and the surgeon. Typically, IUD migration is accompanied by
specific symptoms. However, in this particular case, colonoscopy may
difficulties to extract the IUD. Therefore, it is highly recommended to use
laparoscopic surgery to extract the IUD.
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Copyright holders:
Dwicha Rahmawansa Siswardana, Grady Adrian Dwi Kendra (2023)
First publication right:
AJHS - Asian Journal of
Healthy and Science
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