An atypical presentation of a stromal tumor of the small gut with infiltration of the urinary bladder and formation of a pseudo-bladder in a 58-year-old female patient is described. Operative treatment included resection and construction of an ileal conduit. Clinical management of this disease and recent reports in the literature are discussed. Case Report A 58-year-old lady was admitted in our hospital in August 2005 with complaints of fecalurea, weight loss, and generalized weakness for more than 1 year duration. The patient was admitted for evaluation and put on intra-venous fluids, bowl rest, three way catheter with continuous saline irrigation, antibiotics, multivitamins and amino acids. A baseline assessment was made with a provisional diagnosis of colovesical fistula possibly secondary to diverticulitis, tuberculosis or colon carcinoma. Diverticulitis was excluded because of the rarity of the disease in our region. Tubercular profile, colonoscopy, and ultrasonography all were normal and did not give a significant clue to diagnosis. A CECT of the abdomen did only provide indirect evidence of small bowl involvement but again no preoperative diagnosis could be made. In spite of being on continuous saline irrigation through a three way catheter for many days the patient was still always forming feculent urine.She was subjected to exploratory laparotomy which revealed a mass in the pelvis formed by loops of ileum, by sigmoid colon and partly by the uterus. Once the loops were teased, they broke as flimsy adhesions, revealing the tip of the urinary catheter. On examination in detail, we found that the urinary bladder was completely eaten up by a diffuse ulcerative growth arising from small gut, only the trigone was spared. Two loops of ileum anteriorly, colon on the side and uterus posteriorly had almost formed a pseudo-bladder by flimsy adhesions with each other and around the trigone. Small gut loops were continuously pouring all the contents into this cavity while the sigmoid colon had a doubtful communication with the said cavity. A segmental resection of small gut segments and the sigmoid colon area was planned, and the entire diseased segment of the gut was removed and anastamosed end to end. The case was discussed with an urologist to plan a urinary diversion and with his help an ileal conduit with implantation of both ureters on a stent was made. With the help of a gynaecologist a hysterectomy was performed and the specimen was sent for histopathological examination. Immunohistochemistry (CD 117, c-kit reactive (positive)) confirmed the morphologic diagnosis of a malignant stromal cell tumor.The patient was discharged on the tenth postoperative day but unluckily developed serious depression on follow-up and refused further visits at the department of medical oncology. The ileal conduit was working nicely. The patient died after 9 months secondary to depression and probably to the disease process.
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