Ileovesical Fistula Caused by Hepatocellular Carcinoma
A 27-year-old man was referred to our hospital for the evaluation of hepatic masses. He had consumed 30.0 g alcohol twice weekly for 8 years. On presentation, his vital signs were stable and the physical examination was normal. Liver function test was nonspecific. Viral marker study showed that HBs antigen was negative, anti-HBs antibody positive, and anti-HCV negative. α-fetoprotein (αFP) was over 50,000 IU/mL and carcinoembryonic antigen (CEA) was 4.94 ng/mL. Abdominal computed tomography (CT) with enhancement revealed two heterogeneous hypodense masses in the right hepatic lobe of about 2.4 × 2 cm and 3.4 × 4 cm. No cirrhotic change was observed in the liver. Upper intra-abdominal lymphadenopathy was absent. Liver magnetic resonance imaging (MRI) revealed two relatively well-defined masses in the right hepatic lobe (). These lesions were homogeneous low signal intensity on T1-weighted image and slightly inhomogeneous high signal change on T2-weighted image. The tissue diagnosis was obtained by percutaneous biopsy (). Immunohistochemical stains were positive for cytokeratin (CK), epithelial membrane antigen (EMA), αFP, and hepatocyte-specific antigen (HSA). These findings were compatible with HCC. However, evidence of cirrhosis and chronic injury were absent. Under the diagnosis of HCC, he was treated with transarterial chemoembolization (TACE). Abdominal CT scan was performed during the third week after TACE. The scan showed two lipiodol uptake lesions in the right hepatic lobe. Two months later, follow-up CT scan showed a newly developed mass in the caudate lobe about 4.5 × 4.0 cm in size, with several daughter nodules. A second TACE was performed. Follow-up CT scan after 3 weeks showed defective lipiodol uptake masses in both the right hepatic lobe and the caudate lobe with remnant tumoral enhancement. Thrombus was also observed in the inferior branch of the right portal vein. Several days later, the patient complained of dysuria, fecaluria, and intermittent lower abdominal pain. Pelvic CT scan showed a lobulated soft tissue mass about 6 cm in size (). The mass was abutting on\nthe distal ileum which was downwardly displaced. Barium study of the small bowel showed a fistula between the small bowel loop and the urinary bladder (). We diagnosed this as ileovesical fistula and referred him to the surgical unit.\nLaparotomy was performed under the diagnosis of ileovesical fistula. There were soft tissue masses between the ileum and the bladder and multiple lymphadenopathies at the mesenteric root. Adhesion and fistula were found between the ileum at 10 cm proximal to the ileocecal valve and the dome of the bladder.\nFistula and soft tissue mass were excised. The distal 65 cm of ileum was segmentally resected and anastomosed end-to-end. The bladder was partially resected and closed. Microscopic examination of the surgical specimen showed similar findings to those of liver biopsy. We confirmed that ileovesical fistula had been caused by implanted intraperitoneal metastases of HCC.