PMC6333586_01
(A) Sagittal computed tomography (CT) image of the abdomen and pelvis demonstrating the urachus (white arrows) which connects the urinary bladder (asterisk) and umbilicus (white arrow with black outline). The urachal remnant is thickened and distended with fluid and gas pockets (white arrow heads) consistent with an abscess. Also, the inflammatory stranding of the anterior abdominal wall is evident. (B) Axial CT image of the pelvis demonstrating the thickened wall of the distal ileum (white arrow) contiguous with the urachal remnant (white arrow head). This is suggestive of a fistula between these two structures. The urachal remnant appears edematous with a gas pocket which is consistent with an abscess and the edema extends to involve the adjacent abdominal wall. (C) Sagittal CT image of the abdomen and pelvis taken at an outside facility before the enterourachal fistula formation (5 months prior to this presentation). Urachal remnant (white arrows) extends from the anterior dome of the urinary bladder (asterisk) to the umbilicus (white arrow with black outline). (D) Axial magnetic resonance enterography with volumetric interpolated breath-hold examination image of the pelvis 3 minutes post contrast administration. Fistulous tract between urachal remnant and distal ileum clearly identified (white arrow with black outline). Marked thickening of the distal ileal wall (white arrow) and urachal remnant wall with some fluid remaining in the urachal remnant (white arrow head) consistent with an abscess.
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F1
The CT of the abdomen revealed a rim enhancing ovoid shaped fluid collection in the midline of the suprapubic region (just below the umbilicus) measuring 10.5x3x2.5 cm (Fig. 1A). The CT also revealed significant thickening of the wall of the distal ileum that was in close contiguity with the urachal remnant suggesting the presence of an enterourachal fistula (Fig. 1B). The prior CT performed at the outside hospital at the time of initial presentation was reviewed at our institution and revealed a patent urachus at the same location of the current ovoid shaped abscess (Fig. 1C). Magnetic resonance enterography (MRE) confirmed the CT scan findings and clearly demonstrated a fistula from the TI to the urachal remnant abscess (Fig. 1D).