Acquired Gastrointestinal

Fistulas: Classification,

Etiologies, and Imaging

Evaluation1

Fistulas are abnormal communications between two epithelial-lined surfaces. Gastrointestinal

fistulas encompass all such connections that involve the alimentary

tract, and they can be congenital or acquired in nature. This review focuses on

acquired gastrointestinal fistulas. Development of an acquired gastrointestinal fistula

can greatly affect patient outcome, yet the clinical manifestations are often protean

in nature and the etiology, elusive. Imaging plays an important role in the detection

and management of acquired gastrointestinal fistulas. The more routine use of

cross-sectional imaging (especially computed tomography and magnetic resonance

imaging) has altered the standard sequence of radiologic evaluation for possible

fistulas, but fluoroscopic studies remain a valuable complement, especially for

confirming and defining the anomalous communications. In this review, a classification

scheme for gastrointestinal fistulas is provided, major causes are discussed,

and individual fistula types are elaborated with an emphasis on contemporary

imaging approaches.

Gastrointestinal (GI) fistulas represent abnormal ductlike communications between the

gut and another epithelial-lined surface, such as another organ system, the skin surface, or

elsewhere along the GI tract itself. A GI sinus tract, in comparison, is a similar ductlike

passage that communicates with the gut at one end but ends blindly at the other. The

development of a GI fistula can markedly increase patient morbidity and mortality,

rendering detection of the fistula critical. Imaging often plays a pivotal role in the

diagnosis and management of GI fistula, with fluoroscopic contrast agent–enhanced

studies serving as the traditional standard bearer. The emergence of cross-sectional imaging

techniques, however, has modified the radiologic approach to GI fistulas. Instead of

replacing fluoroscopic contrast-enhanced studies, cross-sectional methods complement

their conventional counterparts in the evaluation of GI fistulas.

In this review, we will provide an organ-system approach to classifying GI fistulas. A

brief discussion of the major causes of acquired GI fistulas will follow. Last, a systematic

review of GI fistulas according to our classification scheme will be provided, with an

emphasis on contemporary imaging evaluation. The relative contribution and effectiveness

of the various imaging modalities will be discussed for individual fistula types,

because many unique features and challenges exist. The salient clinical features of specific

GI fistulas, including management, will also be covered.

CLASSIFICATION OF GI FISTULAS

GI fistulas are generally named according to their participating anatomic components, and

virtually every imaginable combination has been reported in the medical literature. Rather

than recite all possible permutations, a more general approach is presented here (Fig 1).

Because the terminology can be somewhat variable, we have attempted to use fistula

names that prevail in the literature, regardless of underlying etiology. To begin, it is useful

to separate congenital and acquired causes, since their clinical settings and implications

obviously differ greatly. Congenital GI

fistulas are best understood by realizing

their embryologic origin and include

such entities as branchial, tracheoesophageal,

and omphalomesenteric fistulas.

Congenital fistulas, however, are beyond

the scope of this review and will not be

considered further.

Acquired GI fistulas can be categorized

as external or cutaneous if they communicate

with the skin surface or internal if

they connect to another internal organ

system or space, including elsewhere

along the GI tract itself. Internal GI fistulas

can be further divided into two types:

intestinal and extraintestinal. Intestinal

fistulas refer to a gut-to-gut connection

and may consist of any combination of

stomach, small bowel, and colon. An enteroenteric

fistula may refer to any intestinal

fistula in the generic sense, although

some may restrict this term to

small-bowel fistulas only. Extraintestinal

internal fistulas imply communication of

the GI tract with another organ system

such as the genitourinary system, biliary

tree, or respiratory tract. Complex fistulas

contain both internal and external components.

For the purposes of this review,

GI sinus tracts will not be covered in detail,

nor will intentional surgically created

fistulas.

CAUSES OF ACQUIRED GI

FISTULAS

The underlying causes of acquired GI fistulas

are diverse and can include virtually

any process resulting in bowel perforation

from within or bowel penetration

from an extraintestinal process (Fig 2).

The majority of external (cutaneous) fistulas

represent a complication of recent

abdominal surgery (1). The leading causes

of internal fistulas in the industrialized

world are Crohn disease, diverticulitis,

malignancy, or a complication of treatment

of these entities. Not surprisingly,

many cases are the result of multiple contributing

factors; common examples include

cancer patients who have undergone

radiation therapy and patients with

Crohn disease who have undergone prior

bowel surgery. The specific location and

type of fistula can often suggest certain

causes, as will be seen when individual GI

fistulas are covered more in depth. Some

general features of the more common inflammatory

causes will briefly discussed in

the following paragraphs. Most of the remaining

noninflammatory causes listed

in Figure 2 will be covered in more detail

in upcoming sections.

Fistula formation is a hallmark of Crohn

disease, occurring in up to 20%–40% of

patients described in surgical series (2). Sinus

tracts and fistulas often involve the

distal small bowel, and peritoneal abscess

or phlegmon may be an associated finding

(4). The clinical and radiologic manifestations

vary widely because these internal

fistulas can involve nearly any organ system,

but ileocolic and enterovesical fistulas

are the most common types (5). External

fistulas are also common, especially in the

perianal region (6). Fistula formation is

considerably less common in ulcerative colitis,

which, unlike Crohn disease, is not a

transmural process (3). Rectovaginal fistula

is the most frequent spontaneous GI fistula

that develops in ulcerative colitis, followed

by rectovesical fistula (7,8).

Diverticulitis is a common cause of colonic

fistula formation, with the fistula

most often communicating with the urinary

bladder (9). Colovaginal fistulas are

also relatively common in women with

sigmoid colon diverticulitis, particularly

after hysterectomy. Fistulas are seen in

up to 20% of cases of surgically treated

diverticular disease (9,10). Another relatively

common finding in diverticulitis is

a fistulous tract that parallels the colonic

lumen, representing a localized form of

colocolic fistula that has been termed

“double tracking.” Not surprisingly, fistula

formation of the sigmoid colon predominates

in diverticular disease, but

other colonic segments are occasionally

involved.

Other than Crohn disease and diverticulitis,

other less common inflammatory

causes of GI fistulas include atypical infections,

cholecystitis, pancreatitis, and

appendicitis (11,12). Among the various

atypical infectious causes that have been

reported are tuberculosis, histoplasmosis,

actinomycosis, xanthogranulomatous pyelonephritis,

amebiasis, echinococcosis,

and lymphogranuloma venereum (13–19).

OVERVIEW OF IMAGING

TECHNIQUES

Fluoroscopic contrast-enhanced studies

and conventional radiographic studies

have traditionally served as the cornerstone

for imaging of spontaneous GI fistulas.

However, technical advances and

the increased availability of cross-sectional

imaging modalities have challenged

this paradigm. The result has been

a more flexible hybrid approach that utilizes

the strengths of the various complementary

imaging modalities now available.

The preferred imaging approach

will vary according to fistula type and the

specific clinical scenario. Furthermore,

even individual fistula types often elude

generalization and must be treated on a

case-by-case basis. This underscores the

importance of the radiologist in determining

the most appropriate sequence of

imaging studies for a given case. Because

many fistulas may be detected incidentally

on cross-sectional images obtained

because of other indications, familiarity

with the direct and indirect signs of fistulas

is essential for this unsuspected diagnosis.

Despite this wide variability, some

broad comments can be made with regard

to the imaging approach. Once the

selection is made between conventional

and cross-sectional imaging as the initial

study, other technical considerations follow.

Contrast-enhanced fluoroscopic examinations

often remain the initial study

of choice and are generally superior to

endoscopy in demonstrating the presence

and extent of a GI fistula (4). Fistu-

Figure 1. Classification of GI fistulas.

Figure 2. Major causes of acquired GI fistulas.

10 _ Radiology _ July 2002 Pickhardt et al

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lography is adequate for diagnosis of

most external (cutaneous) fistulas and is

also useful for follow-up in these cases

(20). On occasion, enteric contrast-enhanced

studies, such as a small-bowel

study or enema, will provide as much or

more diagnostic information. For extraintestinal

internal fistulas, one must

decide between pursuing a primary bowel

study and a study that directly opacifies

the communicating organ system, such

as urography, vaginography, cholangiography,

and others. For intestinal (gut-togut)

fistulas, enteric contrast-enhanced

studies are superior and may be the only

noninvasive method able to demonstrate

these fistulas in some cases.

The choice of contrast agent is another

important factor in the performance of

conventional GI studies. A water-soluble

iodinated contrast agent is generally

used, at least initially, for abdominal fistulography

and enteric studies when

frank perforation is suspected or pneumoperitoneum

is present. This is predicated

on the potential for extravasated

barium to incite an inflammatory reaction

in the peritoneum, which can be

followed by the formation of dense fibrous

adhesions (21–23). The risk of clinically

important chemical peritonitis,

however, is minimal unless a relatively

large amount of barium has leaked, especially

with the newer barium preparations.

A similar but more localized and

less severe foreign body reaction can occur

with retroperitoneal and extraperitoneal

barium extravasation (24). Despite

these caveats, it is important to remember

that barium is more sensitive than

aqueous contrast agents for demonstrating

GI fistulas due to the tendency of the

latter to dilute, resulting in lower radiographic

opacity (1). This dilution of water-

soluble contrast agents is especially

limiting for small-bowel examination, and

initial evaluation with barium should be

strongly considered in patients without

pneumoperitoneum, particularly for intestinal

(gut-to-gut) fistulas (22). When a water-

soluble contrast agent is used initially, a

negative study should be followed by a barium

study when the index of suspicion

remains high.

For imaging of most internal GI fistulas

with extraintestinal communication, an

aqueous contrast agent is generally preferred.

This is obviously the case when

the extraenteric component is primarily

opacified, as with urographic and cholangiographic

contrast-enhanced studies. A

water-soluble agent should also be used

when there is a possibility of vascular

communication, due to the potentially

life-threatening complication of barium

embolization (25). An exception to this

rule of using an aqueous contrast agent

for imaging of extraintestinal involvement

involves GI fistulas communicating

with the tracheobronchial tree, where

barium is indicated and generally well

tolerated. A water-soluble agent in this

setting can lead to potentially lethal pulmonary

edema due to their relatively

high osmolarity, although the risk is

lower with nonionic agents (26,27). Furthermore,

unless a large esophageal leak

is suspected, barium remains the contrast

agent of choice for esophagography,

since the risk of clinically important mediastinitis

or granuloma formation appears

to be negligible with small amounts

of barium extravasation (27).

Cross-sectional imaging, particularly

computed tomography (CT), has further

strengthened the radiologist’s armamentarium

for evaluating GI fistulas. CT effectively

complements conventional radiography

with its ability to demonstrate

extraluminal disease, including associated

abscesses, tumor, or other coexisting

processes. Although CT may be less sensitive

for direct detection of some GI fistulas,

there are instances where it may be

more sensitive than conventional studies,

such as with enterovesical fistulas

(4,28,29).

Regardless of whether the fistula is directly

detected at CT, CT often yields

more valuable information overall with

respect to patient care. Furthermore, it is

important to at least consider the need

for obtaining a CT scan prior to performing

a conventional barium examination,

because residual barium can produce

troubling artifacts on CT. Technical advances

such as multi–detector row CT

allow for effective multiplanar reformations

and volume-rendering techniques

to directly display fistulas not oriented in

the traditional transverse plane. Often,

CT directly or indirectly demonstrates

the presence of a GI fistula, elucidates the

underlying cause, and obviates further

imaging. An additional advantage of CT

is its utility in guiding percutaneous

drainage of associated abscesses.

Magnetic resonance (MR) imaging

holds similar promise for the evaluation

of certain forms of possible GI fistulas,

but the application of MR imaging has

been most visible in the evaluation of

enterocutaneous fistulas, especially in

the perianal region (30–32). Faster imaging

sequences and the use of oral contrast

agents may further expand the role of MR

imaging in the future, but CT remains

the primary cross-sectional modality for

fistula evaluation because it is rapid, generally

available, and less costly than MR

imaging. Sonography plays a much more

limited role in the evaluation of most GI

fistulas and typically requires a corroborative

study for confirmation (28,33).

The remainder of this review will focus

on the specific forms of GI fistulas.

Figure 3. Enteroenteric and enterocolic fistulas. (a) Frontal radiograph from barium-enhanced

small-bowel study in a 25-year-old man with Crohn disease shows multiple fistulous tracts extending

from the terminal ileum (arrowheads), converging to a small mesenteric cavity (_), and communicating

with the cecum and more proximal ileum (arrows). (b) Transverse contrast-enhanced CT scan

in a 24-year-old man with Crohn disease shows irregular bowel wall thickening, mesenteric infiltration,

and contrast agent–filled extraluminal tracts (arrows) centered in the ileocecal region. This

complex enterocolic fistula involved distal ileum, cecum, ascending colon, and sigmoid colon.

Volume 224 _ Number 1 Acquired Gastrointestinal Fistulas _ 11

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INTERNAL GI FISTULAS

Internal GI fistulas include both intestinal

and extraintestinal types. Although

some of these fistulas may be suspected

on clinical grounds, their presence is often

first discovered at imaging, sometimes

quite unexpectedly. Complex GI

fistulas (Fig 1) may consist of virtually

any combination of internal and external

communication, but for the purpose of

this review each component will be considered

separately.

Intestinal Fistulas

Intestinal (gut-to-gut) fistulas may involve

any or all combinations of the

small bowel, colon, and stomach. The

clinical manifestation of this subset may

be subtle, since only the alimentary tract

is involved. Diarrhea, with or without abdominal

pain, is the most common

symptom overall (9). There are several

factors that influence which segments of

bowel are involved in the fistulous communication.

In cases where a primary

bowel abnormality is the underlying

cause, the segment of diseased bowel will

obviously be at highest risk. Proximity to

the pathologic process, be it intestinal or

extraintestinal, is also important. Finally,

a preexisting or preferred pathway between

certain portions of the gut, as with

a connecting ligament or mesentery, explains

the predisposition for some intestinal

fistulas to form (see discussion of

gastrocolic fistula later).

Enteroenteric and enterocolic fistulas

are common complications of Crohn disease,

where fistulas are often multiple

and favor the ileocecal region (Fig 3). Enterocolic

fistulas in Crohn disease are

usually due to primary small-bowel disease,

whereas the opposite is true for colonic

diverticulitis. Overall, coloenteric

fistulas constitute fewer than 10% of fistulas

complicating diverticulitis (9). A

more common form of intestinal fistula

from diverticulitis is the so-called doubletracking

colocolic fistula (Fig 4). This intraloop

form of intestinal fistula results

from localized perforation and paracolic

extension that parallels the bowel lumen.

A similar appearance can be seen with

Crohn disease and perforated adenocarcinoma

of the colon. Intestinal fistulas

can also be seen in cases of other abdominal

malignancies, radiation therapy, surgery,

and foreign bodies (Fig 5) (34–36).

In general, contrast-enhanced fluoroscopic

GI studies remain the most effective

means for help in diagnosing

intestinal fistulas. When the colon is

involved, a contrast agent enema examination

is the study of choice and will

demonstrate the fistulous communication

more often than an upper GI examination,

due to the increased intraluminal

pressure in the latter (Fig 5) (20). A

small-bowel follow-through examination

may be the only noninvasive means for

detecting some enteroenteric fistulas, but

a successful examination requires vigilance

and a high index of suspicion by

the radiologist. Enteroclysis may be more

sensitive for the detection of some enteroenteric

fistulas, but it is a more invasive

procedure that requires small-bowel

intubation. These fistulas tend to be subtle

on cross-sectional images but may be

detected as a serendipitous finding on

occasion (Fig 6b) (37). Although treatment

principles are similar in many respects

to the enterocutaneous fistulas discussed

later in this article, intestinal

fistulas rarely close spontaneously, and

surgical correction is generally required

(38).

Discussion of all types of intestinal fistulas

is not feasible in this review but one

specific type, the gastrocolic fistula, is

worthy of further attention. The gastrocolic

ligament allows for bidirectional

spread of pathologic processes between

the greater curve of the stomach and the

transverse colon. Although carcinomas

of the stomach and colon were once

thought to be the most common cause of

gastrocolic fistula, it now appears that

most cases are due to penetrating benign

gastric ulcers, particularly in the setting

of nonsteroidal antiinflammatory drug,

or NSAID, use (39). Not surprisingly, various

other neoplastic and inflammatory

causes have also been reported in the literature

(37). Unfortunately, the more

suggestive clinical symptoms of feculent

Figure 4. Colocolic (double-tracking) fistula. (a) Frontal radiograph from air-contrast barium

enema examination in a 50-year-old man 1 month after an episode of acute diverticulitis shows

a long-segment narrowing (arrowheads) involving the sigmoid colon. At the distal aspect of the

stricture, a second channel (arrow) parallels the colonic lumen, the so-called double-tracking

sign. Note additional scattered diverticula. (b) Transverse contrast-enhanced CT scan obtained 1

month earlier than a during an acute episode shows pericolonic inflammatory changes and a

small peridiverticular abscess (arrow). Adjacent large diverticulum (arrowhead) may represent the

point of eventual fistula reentry. Perforation with a localized fistula was confirmed at surgery and

pathologic examination.

Figure 5. Enterocolic fistula. Spot radiograph

obtained during air insufflation for air-contrast

barium enema examination in a 58-year-old

man shows unsuspected communication between

sigmoid colon and small bowel (arrowheads).

The patient had undergone successful

surgical removal of an infected abdominal aortic

graft 6 months earlier. Note also faint contrast

agent (arrow) extending along aortic region.

12 _ Radiology _ July 2002 Pickhardt et al

Radiology

vomiting and undigested food in the

stool are less common than nonspecific

findings such as abdominal pain. Contrast-

enhanced enema examination remains

the most reliable means for detection,

but its superiority over a contrastenhanced

upper GI study has likely been

overemphasized (Fig 6a) (39). Although

barium studies will more often demonstrate

the fistula directly and can usually

suggest a benign or malignant cause, CT

is likely more accurate for evaluation of

the gastrocolic region for the presence of

a bulky mass or alternate cause (Fig 6b).

Most gastrocolic fistulas are treated with

en bloc resection. However, gastrocolic

fistulas due to benign gastric ulcer disease

are the exception, because they may

spontaneously resolve after NSAIDs are

withdrawn (39).

Extraintestinal Fistulas

The extraintestinal fistulas constitute a

diverse and intriguing collection of acquired

GI fistulas since they can connect

the gut with virtually any other organ

system. Extraintestinal fistulas involving

the genitourinary, biliary, vascular, and

respiratory systems are considered below.

Genitourinary tract.—Communication

between the GI and genitourinary tracts

represents a major subset of extraintestinal

internal fistulas. The bladder and vagina

are most often affected, but involvement

of the upper collecting system,

urethra, or uterus is occasionally seen.

Available diagnostic modalities for evaluating

these lesions include urographic

studies, contrast-enhanced GI studies,

cross-sectional imaging, and endoscopic

procedures. The most appropriate initial

study varies according to fistula type, and

the management approach continues to

evolve. Both CT and MR imaging have

proved to be useful for noninvasive evaluation

of pelvic fistulas (30,31).

The term enterovesical fistula is often

generally applied for bladder communication

with the colon, small bowel, rectum,

or appendix (28,40). Sigmoid diverticulitis

is the single most common cause

of enterovesical (specifically, colovesical)

fistula (9). Furthermore, fistulas to the

urinary bladder account for over half of

all internal fistulas encountered in diverticular

disease (Fig 7). Crohn disease accounts

for most small-bowel–to-bladder

fistulas and may be present in up to

3%–4% of patients with this disease (Fig

(29). Pelvic malignancy, especially

colorectal adenocarcinoma, is the other

major cause of a GI fistula to the bladder,

followed by radiation- and surgically induced

fistulas. Approximately 20% of all

enterovesical fistulas are rectovesical, and

fewer than 5% are appendicovesical (Fig

9). Specific clinical symptoms (fecaluria

and pneumaturia) are present in 40%–

70% of patients, but nonspecific symptoms

such as cystitis are invariably

present (9,28,40–42).

Cystoscopy usually demonstrates inflammatory

changes in the bladder but is

nondiagnostic for fistula in the majority

of cases (9,28,40,41). Likewise, conventional

contrast-enhanced genitourinary

and GI studies such as cystography and

barium enema examination also yield

false-negative results in most cases, as do

Figure 6. Gastrocolic fistulas. (a) Frontal radiograph from solid-column barium enema examination

in a 57-year-old man shows fistulous communication between the transverse colon and

stomach via a large benign gastric ulcer (_) extending into the gastrocolic ligament. Note smooth

folds radiating from the ulcer crater and absence of a gastric or colonic mass. (b) Contiguous

transverse contrast-enhanced CT scans in a 59-year-old woman with abdominal pain and vomiting

show pericolonic inflammatory changes surrounding a large transverse colonic diverticulum

(arrows) in the gastrocolic region. The process blends imperceptibly with thickened gastric

antrum (arrowheads). (c) Image from contrast-enhanced enema examination in the same patient

as in b shows gastrocolic fistula (arrowhead), which proved to be secondary to diverticulitis at

surgery and pathologic examination.

Volume 224 _ Number 1 Acquired Gastrointestinal Fistulas _ 13

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sonography and GI endoscopy. CT, however,

has demonstrated 90%–100% sensitivity

for diagnosis (albeit with the use

mainly of indirect signs and not direct

demonstration of the fistula itself) and

has been advocated for initial evaluation

(28,41). Diagnostic CT findings that are

present with most enterovesical fistulas

include air in the bladder lumen (in the

absence of recent catheterization) associated

with focal bladder and/or bowel wall

thickening (Figs 7–9) (28). Conventional

studies are much less sensitive and specific

for the detection of intravesical air.

Although the fistula itself is often not

directly demonstrated at CT (Fig 9), its

location can generally be inferred from

the secondary findings (Figs 7, 8). Furthermore,

if an intravenous contrast

agent is not used, the presence of an enteric

contrast agent in the bladder on CT

scans is diagnostic of a fistula. Alternatively,

if an enteric contrast agent is not

used, the presence of an intravenous contrast

agent in the bowel is also diagnostic.

Sensitivity can be increased further with

direct rectal administration of a contrast

agent or with a CT cystographic technique.

Rescanning after active urination

and defecation may also be useful when a

suspected fistula is not demonstrated on

the initial scan. CT can also provide important

extraluminal information, such

as the presence of an offending tumor

(Fig 8). More recently, MR imaging has

shown similar success in facilitating diagnosis

(30). Treatment of enterovesical fistulas

consists of single-stage surgical resection

in the majority of cases (40,41).

GI fistulas to the kidney or upper urinary

tract are much less common than

bladder fistulas and are more often due to

urologic disease rather than a primary GI

process (17,43,44). The “retroperitonealized”

portions of the colon and duodenum

are most often involved. Communication

of the colon with the pelvicaliceal system

(renocolic fistula) or the ureter (ureterocolic

fistula) typically occurs secondary

to chronic suppurative renal infection in

the setting of urolithiasis and/or obstruction,

as seen with xanthogranulomatous

pyelonephritis (17,43,45). Less common

causes include tuberculosis, trauma, surgery,

radiation therapy, Crohn disease,

diverticulitis, and malignancy (Fig 10) (46–

48). Although fecaluria and pneumaturia

may be present, the clinical picture more

often is nonspecific and related to chronic

or recurrent urinary tract infection (44).

The combination of urography and CT

is a useful approach in the evaluation for

possible GI fistulas involving the kidneys

and upper urinary tract (Fig 10) (43). Urographic

studies are best for direct visualization

of the fistula, and CT can be used

to reliably assess the involved organs and

surrounding tissues for the cause and extent

of disease. It is important to note,

however, that an excretory urogram will

fail to opacify the fistula when the kidney

is nonfunctioning, and a retrograde

study may be nondiagnostic if an obstruction

is present distal to the fistula.

Direct antegrade pyelography can be useful

in these situations (49). Surgical excision

of the fistula, often with nephroureterectomy,

is necessary in most cases.

The acquired rectovaginal fistula is the

most common GI fistula involving the

genital tract in women. Most cases are

related to obstetric complications, inflammatory

bowel disease, or some combination

of gynecologic malignancy (particularly

cervical cancer), surgery, and

radiation therapy (7,50). Although the

clinical symptoms, particularly the passage

of feces through the vagina, usually

indicate the presence of a fistula, its detection

is often difficult on conventional

GI studies unless a relatively large communication

is present (Fig 11). Vaginography

may demonstrate the fistula more

clearly in subtle cases (51). More recently,

CT and MR imaging have been shown to

be useful for detection of rectovaginal

and enterovaginal fistulas, whereas endorectal

sonography appears to be relatively

insensitive (30,33,52). An enteric contrast

agent and/or air within the vagina

can be demonstrated on CT scans in the

majority of cases (52). Simple excision is

often not adequate in these complex

cases, and at least temporary colonic diversion

is usually necessary. GI fistulas

involving the uterine body and fallopian

tubes are rare, compared with vaginal fistulas,

and most often involve the left side

of the colon (53). Most colouterine and

colotubal (salpingocolic) fistulas result

from diverticulitis, but a variety of other

GI and genitourinary causes are possible,

especially in younger women (9,53). Actinomycosis

should be considered in the

setting of an intrauterine device. A combination

of hysterosalpingography and

CT will provide a comprehensive preoperative

assessment in most cases (Fig 12).

Acquired rectourethral fistulas in males

are also rare, with the majority of cases

related to treatment for prostate cancer

(Fig 13) (54).

Biliary tract.—Spontaneous internal biliary

fistulas represent a complication of

cholelithiasis or choledocholithiasis in

over 90% of cases (11,55). Infrequent

causes include peptic ulcer disease, malignancy,

and prior surgery. In most series,

cholecystoduodenal fistulas are the

most common type, followed by cholecystocolic

and choledochoduodenal fistulas

(11). The clinical manifestation of

enterobiliary fistulas is often nonspecific,

and most cases are diagnosed on the basis

of an unsuspected imaging finding (11).

Distal small-bowel obstruction from an

impacted ectopic gallstone, so-called

gallstone ileus, is an unusual complication

of chronic cholecystitis and affects

only a minority of patients with cholecystoduodenal

fistulas. Gallstones that

result in intestinal obstruction typically

exceed 2 cm in diameter (56). Obstruction

at the level of the gastric outlet or

duodenum represents a specific subset of

gallstone ileus that is referred to as Bouveret

syndrome (57). Surgery is indicated

to relieve the obstruction in cases of gall-

Figure 7. Colovesical fistula. Transverse contrast-enhanced CT scans in a 56-year-old-man with

pneumaturia and prior diverticulitis show air (arrowhead) in the bladder and the site of fistulous

communication (arrow) between sigmoid colon and bladder. Note diverticulosis of the sigmoid

colon.

14 _ Radiology _ July 2002 Pickhardt et al

Radiology

stone ileus, and surgical correction is required

for the biliary fistula, to prevent

future complications.

Pneumobilia seen on imaging studies

strongly suggests the presence of an internal

biliary fistula in the absence of prior

sphincterotomy, surgical bypass procedure,

recent endoscopic retrograde cholangiopancreatography,

or passed common

duct stone. The Rigler triad of small-bowel

obstruction, pneumobilia, and ectopic

gallstone(s) is virtually pathognomonic

for gallstone ileus but is present on conventional

radiographs in only 30%–35% of

cases (Fig 14a) (58). This triad of findings,

however, is more readily apparent on CT

scans (Fig 14b) (59). CT can also provide

important information on the degree of

bowel obstruction and suggest the likely

site of fistula formation. Endoscopic retrograde

cholangiopancreatography is a

sensitive technique for direct demonstration

of enterobiliary fistulas, especially

those of the choledochoduodenal type.

Conventional contrast-enhanced GI studies

are somewhat less direct for direct

demonstration but nonetheless are relatively

noninvasive and may help detect

an unsuspected communication with the

biliary tree (Fig 15). Compared with CT,

sonography is less accurate for detection

of cholecystoenteric fistulas, but suggestive

findings include an irregular contracted

gallbladder, nonvisualization of

the gallbladder, and pneumobilia (56).

Vascular system.—Enteric fistulas involving

the vascular system, whether arterial

or venous, are potentially lethal

and often require urgent correction. A

high index of clinical suspicion is necessary,

since a favorable outcome relies on

prompt diagnosis. Imaging studies, particularly

CT and contrast-enhanced GI

studies, play an important role in the preoperative

detection of these fistulas.

The aorta lies in proximity with the GI

tract for much of its thoracic and abdominal

course. Aortoenteric fistulas, therefore,

can potentially involve the gut anywhere

from the esophagus to the colon

(60–62). The majority of cases occur in

the presence of aortic aneurysm disease,

either as a primary event or a secondary

complication following surgical repair

(60). Aortic fistulas involving the duodenum

and esophagus warrant further consideration.

The duodenum participates in the majority

of aortoenteric fistulas, owing to the

proximity between its third portion and

the underlying abdominal aorta. Primary

aortoduodenal fistula is a rare life-threatening

cause of gastrointestinal bleeding that

results most commonly from an atherosclerotic

aortic aneurysm (60,63). Unusual

causes of a primary fistula include aortitis,

radiation therapy, malignancy, and peptic

ulcer disease (64,65). Most patients have

upper or lower GI bleeding, but the classic

triad of abdominal pain, GI bleeding, and

pulsatile mass is present in fewer than

25% of cases (60,66). A “herald bleed”

frequently precedes lethal exsanguination,

and patient survival hinges on

prompt diagnosis and emergent therapeutic

laparotomy. Unfortunately, a cor-

Figure 8. Enterovesical fistula. (a) Contiguous

transverse CT scans obtained with intravenous

and oral contrast agents in a 69-year-old

woman with longstanding Crohn disease

show a heterogeneous soft-tissue mass (M) associated

with thickened ileal loops and adjacent

bladder wall thickening (arrowhead). A

small gas bubble (arrow) is present in the bladder

lumen. (b) Fluoroscopic image shows contrast

agent injection through a communicating

enterocutaneous fistula and demonstrates

the fistula (arrowhead) between the ileal segment

and bladder. Small-bowel adenocarcinoma

complicating Crohn disease was proved at

surgery.

Figure 9. Rectovesical fistula. Transverse contrast-

enhanced CT scan in a 65-year-old-man

with ulcerative colitis shows air in a fistulous

tract (arrow) between inflamed rectum and

bladder. Note also air (arrowheads) in bladder

lumen.

Volume 224 _ Number 1 Acquired Gastrointestinal Fistulas _ 15

Radiology

rect preoperative diagnosis is determined

in only a minority of cases, underscoring

the importance of heightened clinical

suspicion (60). Endoscopy is often the

initial diagnostic study performed, but

blood pooling may impair luminal visibility,

and an alternate presumed source

of bleeding is frequently identified, acting

as a “red herring” (60). Conventional

upper GI study, sonography, aortography,

and tagged red blood cell scintigraphy

all have marked limitations for diagnosis

(67). CT, however, provides rapid

and effective evaluation in hemodynamically

stable patients suspected of having

an aortoenteric fistula. CT findings such

as perianeurysmal hematoma, pseudoaneurysm,

contrast agent extravasation,

periaortic or intraluminal gas, and focal

duodenal wall thickening are highly suggestive

of a fistula in the appropriate clinical

setting (Fig 16a) (63,67,68).

Secondary aortoduodenal fistulas develop

in fewer than 2% of aortic reconstructions

but are still more common

than primary fistulas (60,69). Clinical

suspicion remains the linchpin for diagnosis

of this condition, which must be

considered in any patient with a prosthetic

aortic graft and GI bleeding. As

with primary fistulas, endoscopy and CT

are the most useful diagnostic studies for

initial evaluation in hemodynamically

stable patients (69). However, although

endoscopy may reveal mucosal defects or

even graft eroding into the duodenum, it

is diagnostic in fewer than 25% of cases

(69). CT is a sensitive technique but its

specificity for the diagnosis of fistulas is

relatively low, especially in the early

postoperative period when perigraft fluid

and gas can be a normal finding. The CT

appearance of secondary aortoenteric fistula

overlaps substantially with that of

graft infection, although the presence of

extraintestinal air and associated duodenal

abnormality is less common in the

latter (Fig 16b) (70,71).

Aortoesophageal fistulas are rare; in

the majority of cases, they are caused by

localized rupture of a thoracic aortic aneurysm

(72,73). Unusual reported causes

include esophageal carcinoma, foreign

body ingestion, syphilis, and infected

aortic graft (73–76). The clinical manifestation

is fairly characteristic and is de-

Figure 10. Ureteroduodenal fistula. (a) Frontal radiograph obtained after retrograde contrast

agent injection of right upper urinary collecting system in a 67-year-old man shows contrast

agent within the duodenum (arrows) from an unsuspected fistula. Note wire (black arrowheads)

and small amount of retained contrast agent (white arrowhead) in the collecting system. (b) Contrast-

enhanced CT scan performed after a shows site of contact (white arrowhead) between

duodenum and right ureter. The fistula likely resulted from injury during previous aortofemoral

bypass surgery. Note vascular graft (black arrowhead) and right ureteral stent (arrow).

Figure 11. Rectovaginal fistula. Lateral radiograph

from air-contrast barium enema examination

in a 38-year-old woman with ulcerative

colitis shows air and contrast agent within the

vagina (V). The site of communication (arrow)

is visible inferiorly. The rectosigmoid region

appears somewhat foreshortened and featureless.

Figure 12. Salpingocolic (colotubal) fistula.

Frontal pelvic radiograph from hysterosalpingogram

in a 28-year-old woman with a history

of pelvic inflammatory disease shows left hydrosalpinx

and contrast agent filling a tuboovarian

abscess cavity (A), with extension superiorly

into the left side of the colon

(arrowheads).

Figure 13. Rectourethral fistula. Oblique radiograph

from retrograde urethrogram in a 64-

year-old man with a history of brachytherapy

for prostate cancer shows contrast agent in the

rectum (arrowheads). Contrast agent entered

the rectum via a large communication with the

prostatic urethra (arrow). As expected, contrast

agent is also present in the anterior urethra

and bladder (B). Note radiopaque brachytherapy

implants in prostatic region.

16 _ Radiology _ July 2002 Pickhardt et al

Radiology

scribed by the Chiari triad: midthoracic

pain or dysphagia, a sentinel episode of

hematemesis, and a symptom-free interval

that gives way to massive upper GI

bleeding (73,76). Diagnosis prior to exsanguination

is obviously imperative for

successful surgical repair. The chest radiograph

will typically demonstrate the

presence of an enlarged or tortuous thoracic

aorta (72). In stable patients, the

combination of CT and contrast-enhanced

esophagography will usually be

diagnostic. The esophagogram will usually

demonstrate deviation of the esophagus

due to the aneurysm, with or without

ulceration (Fig 17b) (72). The CT

findings are analogous to those seen with

aortoduodenal fistulas (Fig 17a). Aortography

was performed in the past but provides

less information than does chest CT

and only rarely will show the fistula directly

(72,77).

Other than typical portomesenteric venous

gas due to intestinal ischemia,

pneumatosis, and other causes, true enterovenous

and colovenous fistulas are

rare but potentially lethal entities. The

most common reported causes of duodenocaval

fistula include migration of caval

filters, right nephrectomy, peptic ulcer

disease, and ingestion of a foreign body

(78). Fistulas involving the mesenteric

small bowel and the colon are usually

secondary to Crohn disease and diverticulitis,

respectively (79,80). These fistulas

are often detected unexpectedly on barium

studies by observing intravasation of

the contrast agent (Fig 18). Substantial

barium intravasation reportedly carries a

high mortality rate (25,81). If the patient

survives the acute episode, diffusely increased

opacity of the spleen, greater

than that of the liver, can be seen on

both radiographs and CT scans due to

reticuloendothelial uptake of the barium

sulfate (81,82).

Respiratory tract.—Acquired esophagorespiratory

fistulas account for the majority

of intrathoracic GI fistulas and consist

of communication with either the tracheobronchial

tree or the pleura. Fistulas

that communicate between the respiratory

tract and the intraabdominal GI

tract (ie, gastrobronchial, enterobronchial,

and colobronchial fistulas) are rare

but may result from a penetrating subphrenic

abscess or a postsurgical complication

(83,84). Likewise, gastropleural

and colopleural fistulas are also rare and

are usually associated with diaphragmatic

herniation or prior pulmonary resection

(85–87). Of these GI-respiratory

fistulas, communication of the esophagus

with the tracheobronchial tree and

the pleura warrants further consideration.

Direct invasion by esophageal carcinoma

is the most common cause of acquired

tracheoesophageal and bronchoesophageal

fistulas, seen in approximately

5% of cases (88,89). Fistulas are especially

common following radiation therapy in

these patients. Other causes of tracheoand

bronchoesophageal fistulas include

primary lung and tracheal carcinoma,

Figure 14. Gallstone ileus from cholecystoduodenal fistula. (a) Supine radiograph in a 76-year-old woman shows bowel gas pattern suggestive of

small-bowel obstruction, two ectopic calcified gallstones (arrowheads), and air in the biliary tree (arrows). These findings constitute the Rigler triad.

(b) Transverse CT scans obtained without intravenous contrast agent in an 85-year-old woman show pneumobilia (arrowheads) and high-grade

small-bowel obstruction from an ectopic gallstone (short arrow). Note also orthotopic gallstones (long arrow) with a similar appearance.

Figure 15. Cholecystocolic fistula. Spot radiograph

from barium enema examination in

an 81-year-old man with nonspecific abdominal

complaints shows contrast agent within

the gallbladder (*) from communication with

the hepatic flexure. Air (arrowheads) is present

within the biliary tree.

Volume 224 _ Number 1 Acquired Gastrointestinal Fistulas _ 17

Radiology

esophageal instrumentation, tracheal

intubation, trauma, presence of foreign

bodies, and granulomatous infection

(89 –91). Patients typically present with

dysphagia and symptoms suggestive of

aspiration. The barium esophagogram

remains the study of choice, because it

effectively differentiates fistula from aspiration

(Fig 19a, 19b). The lateral projection

will generally best define tracheoesophageal

fistulas, whereas bronchoesophageal

fistulas may require a slightly different

obliquity. As previously mentioned, aqueous

contrast agents should be avoided because

of the risk of potentially lethal pulmonary

edema. CT can be a useful adjunct

in selected cases for evaluation of the

underlying cause or assessment of tumor

burden (Fig 19c). Treatment options for

malignant fistulas include palliation with

gastrostomy or jejunostomy, surgical bypass

or correction, and endoprosthetic

stent placement (88,92). For benign fistulas,

the goal of treatment is generally to

achieve definitive repair (89).

Esophagopleural fistulas are perhaps

best considered as a subset of esophageal

perforation and usually result from prior

surgery, endoscopic procedures, esophageal

carcinoma, or radiation therapy (93).

Clinical diagnosis is often difficult due to

inconstant and nonspecific symptoms,

especially in the absence of substantial

mediastinal involvement (93). Chest radiography

in patients with esophagopleural

fistulas will demonstrate either

pleural effusion or hydropneumothorax

on the affected side in essentially all

cases. Conventional esophagography is

indicated for confirmation and localization

of esophagopleural fistulas (Fig 20b).

CT can also demonstrate pleural air,

fluid, and/or contrast agent and can

sometimes demonstrate the fistula itself

(Fig 20a, 20c) (94).

Other fistulas.—Less common sites for

extraintestinal GI fistula formation include

the pericardium, pancreas, and skeletal system.

Fistula formation between the pericardial

space and the esophagus or stomach

should be considered in the setting of

nontraumatic spontaneous pneumopericardium.

Most esophagopericardial fistulas

are due to direct invasion from esophageal

cancer or a complication of treatment for

the cancer, whereas most gastropericardial

fistulas result from benign penetrating gastric

ulcers (95,96). In stable patients, CT

findings will help confirm the presence of

pericardial air and often suggest the underlying

cause (Fig 21a), while fluoroscopic

upper GI examination with a water-soluble

contrast agent is the simplest method for

directly demonstrating the pericardial communication

(Fig 21b). Endoscopy can also

be performed, but there is a potential risk

of inducing pericardial tamponade from

air insufflation (97).

Fistulas complicating surgical de´bridement

for severe necrotizing pancreatitis

are most often enterocutaneous and/or

pancreatricocutaneous, but internal pancreaticoenteric

communication is demonstrated

on rare occasions (12,98). Fistulas

may also form from spontaneous

rupture of a pseudocyst or peripancreatic

fluid collection into the stomach, colon,

or duodenum. In some cases, this transenteric

pseudocyst rupture will ameliorate

symptoms and serve a therapeutic

function. Depending on the situation,

conventional contrast-enhanced GI studies,

endoscopic retrograde cholangiopancreatography,

and/or CT can provide useful

diagnostic information (Fig 22).

Direct extension of GI inflammatory

and neoplastic processes to the abdominal

wall musculature, such as the psoas

and rectus abdominis, is common but

Figure 17. Aortoesophageal fistula. (a) Transverse contrast-enhanced CT scan in a 52-year-old

man with hematemesis and prior repair of thoracic aortic aneurysm with an endoluminal

stent-graft shows air (arrowhead) in the aortic lumen adjacent to the stent-graft. Irregular air

collection is also present in the expected region of the esophagus (arrow). (b) Oblique radiograph

from contrast-enhanced esophagogram directly demonstrates aortoesophageal fistula (arrows),

which was confirmed at surgery.

Figure 16. Primary and secondary aortoduodenal

fistulas. (a) Primary aortoduodenal fistula.

Transverse nonenhanced CT scan in an

80-year-old woman with GI bleeding shows a

calcified abdominal aortic aneurysm (A) with

intraluminal gas (arrow). Massive high-attenuation

retroperitoneal hemorrhage (H) surrounds

the aorta. (b) Secondary aortoduodenal

fistula. Contiguous transverse contrast-enhanced

CT scans in a 71-year-old man with GI

bleeding and history of aortic repair shows air

(black arrow) in the lumen of the aortic graft

and tethering (white arrow) of overlying duodenum

associated with periaortic inflammatory

changes.

18 _ Radiology _ July 2002 Pickhardt et al

Radiology

generally considered to represent a sinus

tract and not a true fistula when it is

contained. Rare acquired GI fistulas with

the skeletal system include colonic communication

with the hip (colocoxal) and

bowel communication with the spine

(enterospinal and colospinal) (99–102).

The mechanism for formation of these

fistulas is typically multifactorial, with

varying combinations of GI and orthopedic

surgery, radiation therapy, malignancy,

and inflammatory disease.

EXTERNAL (CUTANEOUS)

FISTULAS

Notwithstanding the deliberate creation

of a gastrostomy, jejunostomy, or colostomy,

the majority of unintended enterocutaneous

fistulas represent a complication

of prior surgery. Diverticulitis,

appendicitis, Crohn disease, and other

causes listed in Figure 2 may also manifest

with a spontaneous external fistula

on occasion (1). Perianal fistulas are

somewhat unusual in that most appear

to be idiopathic in nature or due to

Crohn disease; these will be considered

separately at the end of this section (103).

Factors that predispose to postoperative

enterocutaneous fistula formation

include anastomotic failure (eg, due to

inadequate blood supply, diseased bowel,

undue tension), adjacent abscess formation,

distal obstruction, and certain underlying

disease processes (12,104). Many

of these same factors will also influence

the likelihood of spontaneous closure of

such fistulas. Enterocutaneous fistulas are

further categorized according to their degree

of fluid production. High-output fistulas

drain more than 100–200 mL/day

and generally originate in the upper GI

tract, whereas low-output fistulas drain

less than this amount and are typically

more distal. Clinical management issues

beyond diagnosis and treatment of the

fistula itself include addressing potential

electrolyte imbalances, sepsis, malnutrition,

and wound care (105).

Enterocutaneous fistulas can be adequately

delineated and followed with fistulography

in the majority of cases (Fig

23) (20). In some instances, the fistulous

tract may be shown to equal or better

advantage with use of an intraluminal

enteric contrast agent (Fig 22). The most

common approach for fistulography is to

gently insert a soft-tipped catheter and

inject a water-soluble contrast agent with

fluoroscopic guidance to opacify the

tract. Contrast agent injection into an

existing surgical drain can also yield informative

findings. In addition to a variety

of occlusive adaptors and balloons to

obturate the skin site, it is often useful to

have the able patient hold the catheter

firmly in place during contrast agent in-

Figure 19. Tracheoesophageal and bronchoesophageal

fistulas. (a) Lateral radiograph from

barium esophagogram in a 61-year-old man

with esophageal cancer shows contrast agent

delineating tracheoesophageal communication

(arrowhead). Note widening of tracheoesophageal

stripe (_) and mass effect on the trachea

from tumor. (b) Lateral radiograph from barium

esophagogram in a 61-year-old man with

recurrent pneumonia shows fistula (arrow) between

esophagus and airway that was secondary

to histoplasmosis. (c) Reformatted oblique

transverse multi–detector row helical CT scan

in a 47-year-old man with bronchogenic carcinoma

shows irregular fistulous tract extending

from the left bronchial tree (black arrowhead)

to the esophagus (black arrow). Five standard

transverse CT images (not shown) were needed

to sequentially demonstrate the oblique course

displayed on this single reformatted image.

Note oral contrast agent (white arrow) in segmental

bronchus and peripheral airspace consolidation

(white arrowhead). The patient was

treated with a covered esophageal stent.

Figure 18. Colovenous fistula. Postevacuation

radiograph from barium enema examination

shows contrast agent throughout the inferior

mesenteric venous system (arrowheads).

Colovenous fistula was due to diverticulitis.

Note extensive sigmoid diverticulosis in this

region. (Case courtesy of Charles A. Rohrmann,

MD, Seattle, Wash.)

Volume 224 _ Number 1 Acquired Gastrointestinal Fistulas _ 19

Radiology

jection. Although fistulography will usually

demonstrate the bowel connection

and any large communicating abscess,

CT is usually performed in conjunction

not only to help identify all abscess cavities

but also to guide percutaneous drainage

of any abscesses found (106,107). In

current practice, external fistulas and associated

abscesses are often first discovered or

evaluated on CT scans, especially if the fistulous

tract extends only to the subcutaneous

tissue (Fig 24). Hydrogen peroxide–enhanced

sonography has been used recently

at some centers to delineate enterocutaneous

fistulas (108).

Conservative medical therapy, consisting

of total parenteral nutrition and somatostatin

analogues, constitutes the

standard initial approach to most postop-

Figure 20. Esophagopleural fistulas. (a) Transverse

nonenhanced CT scan in a 43-year-old

woman shows large air-fluid collection in left

pleural space (P) that encroaches on the esophagus

(arrow). (b) Subsequent esophagogram

shows contrast agent leak (arrowheads) from

the distal esophagus into empyema. (c) Transverse

contrast-enhanced CT scan in a 29-yearold

man with a history of radiation therapy for

Hodgkin disease shows communication (arrow)

between esophagus and apical hydropneumothorax

(P). L _ aerated right upper

lobe.

Figure 21. Gastropericardial and esophagopericardial fistulas. (a) Transverse contrast-enhanced

CT scan in an 82-year-old woman with spontaneous pneumopericardium (P) shows hiatal hernia

with inflammatory changes (arrowheads) adjacent to the pericardium. Gastropericardial communication

(arrow) is suggested and was confirmed at fluoroscopic examination with water-soluble

contrast agent (not shown). A penetrating benign gastric ulcer was the underlying cause.

(b) Oblique esophagogram in a 73-year-old man with spontaneous pneumopericardium after

distal esophagectomy for cancer shows contrast agent filling the pericardial space (arrowheads)

via the esophagopericardial fistula. (Case courtesy of Charles A. Rohrmann, MD, Seattle, Wash.)

Figure 22. Pancreaticocolocutaneous fistula.

Frontal radiograph from barium enema examination

in a 55-year-old man with severe pancreatitis

shows contrast agent filling an irregular

retroperitoneal collection (_) extending

from the region of the pancreatic tail. Communication

with the pancreatic ductal system is

not apparent. Note also colocutaneous fistula

(arrowheads).

Figure 23. Enterocutaneous fistula. Oblique

radiograph from pelvic fistulogram in a 29-

year-old man with abdominal tuberculosis

shows enterocutaneous fistula (arrowheads).

Note second cutaneous fistula (arrow) that

communicates with injection site.

20 _ Radiology _ July 2002 Pickhardt et al

Radiology

erative enterocutaneous fistulas (109,110).

Adjunctive measures include an appropriate

antibiotics regimen and correction of

electrolyte abnormalities. Surgical correction

is generally indicated when conservative

measures have failed or if peritonitis

develops (38,109,110). Failure of conservative

therapy is not a trivial matter, because

the mortality rate for surgical management

approaches 25% in some series (111). Percutaneous

catheter management by the radiologist

for enterocutaneous fistulas has

been shown to be a feasible alternative to

surgery in patients in whom medical treatment

has failed (111). This approach utilizes

fistulography to guide cannulation of

the fistulous tract by means of catheter and

guidewire manipulation, as well as CT for

detection and drainage of abscesses not

communicating with the main fistulous

tract. A 90% success rate for this nonsurgical

approach has been shown in high-output

fistulas in which conservative therapy

has failed (111). The closure rate for the

low-output fistulas (65%) is somewhat

lower, and these fistulas also require more

time to resolve than do high-output fistulas.

As mentioned earlier, perianal fistulas

represent a unique subset of external fistulas.

In the majority of cases, preoperative

imaging is not necessary and patients

generally do well with simple

fistulotomy (103). In a minority of complex

cases, however, preoperative imaging

will be necessary to provide a road

map for surgery. The primary goals of

imaging are to determine if the fistula

traverses the external sphincter (transsphincteric)

or levator ani muscles and to

identify any secondary fistulous tracts or

abscess cavities that could lead to treatment

failure (32). Most attempts at preoperative

imaging with conventional fistulography,

endoscopic sonography, and

CT have failed to surpass the accuracy of

the clinical examination (112–114). MR

 

Introduction

Enterovesical fistula (EVF) is an abnormal communication

between the bladder and the intestine related to a

variety of inflammatory and neoplastic conditions. EVF

account for approximately 1 in 3000 hospital admissions

[1]. They are diagnosed primarily on clinical grounds

with over 75% of affected patients describing pathognomonic

features of pneumaturia, faecaluria and recurrent

urinary tract infections [2]. Pre-operative studies should

characterize the anatomical abnormality and exclude

underlying malignancy as well as visualizing the fistulous

tract where possible. Several clinical reports have advocated

the use of computed tomography (CT) scanning as

having the highest sensitivity in identifying a fistula and

its relationship to the surrounding soft tissue structures

[3,4]. However, there is little evidence supporting a

specific investigative algorithm [5]. Diverticular disease

accounts for over two-thirds of cases, the remainder

being caused by malignancy, radiation or fistulating

Crohn’s disease [6]. The management of EVF is associated

with considerable morbidity and mortality. In some

studies surgical-related morbidity is reported to be as

high as 45% [7].

The purpose of this study was to

• evaluate the variation in clinical presentation of EVF in

a specialist colorectal unit;

• determine the value of several investigations in determining

the diagnosis and aetiology of the EVF;

• define the optimal investigative algorithm;

• evaluate outcome following conservative vs surgical

management.

Patients and methods

This retrospective study was performed in a colorectal

specialist unit in a tertiary referral centre. The time

period studied encompassed all patients referred to the

unit over a 10-year period (1990–2000). All patients

with a clinical suspicion of or an established diagnosis

Correspondence to: Dr Dara Kavanagh, Research Registrar, Department of

Surgery, St Vincent’s University Hospital, Elm Park, Dublin 4, Ireland.

E-mail: dara_kav@hotmail.com

286 _ 2005 Blackwell Publishing Ltd. Colorectal Disease, 7, 286–291

of an EVF referred to our unit were included in the

study.

Specific parameters recorded for all patients included

demographics, referral pattern, clinical presentation,

mean time from clinical presentation to diagnosis, investigations,

aetiology, intestinal origin of the fistula, conservative

vs surgical treatment, type of surgical procedure,

surgical complications and clinical outcome. The investigations

performed were variable and often dictated by

the referring physician. Each patient had either endoscopic

or contrast evaluation of the involved system. CT

scan was reserved for further evaluation and delineation

of the disease process. Clinical outcome was defined as

complete symptomatic relief, symptomatic recurrence of

the EVF, peri-operative mortality (defined as death

within 30 days of surgery) or death due to disease

progression.

A single experienced colorectal surgeon undertook all

surgical procedures in conjunction with a single urologist

as indicated. In the elective setting a colonic resection

with primary anastomosis was performed provided both

ends were well vascularized and easily approximated

without tension. In the setting of sepsis, resection and

diversion (i.e Hartmann’s procedure) was required. In

selected cases where sepsis was irradicated successfully, a

resection with primary anastomosis was performed [8]. In

a limited number of cases a proximal faecal diverting

stoma was used where symptom palliation was the

primary objective. All patients were counselled preoperatively,

where possible by a stoma therapist and the

optimum site for stoma fashioning was marked. Patients

were followed up at outpatients for a mean of six months

(Range 4–16 months).

Results

Thirty patients were identified, 14 males and 16 females.

Nine had a previously undergone hysterectomy.

The mean age at presentation was 63.5 years (range

23–90 years). Referral sources included urology (n ¼ 9),

accident and emergency (n ¼ 9), general practitioner

(n ¼ 7) and another centre (n ¼ 5) (Table 1).

Presenting features included faecaluria (n ¼ 12),

pneumaturia (n ¼ 12), recurrent urinary tract infections

(n ¼ 14), altered bowel habit (n ¼ 14), systemic sepsis

(n ¼ 4), haematochezia (n ¼ 2), passage of urine per

rectum (n ¼ 2), haematuria (n ¼ 1) and suspected

incarcerated spigelian hernia (n ¼ 1). Two patients had

coexistent enterocutaneous fistula at initial presentation.

The mean time from clinical presentation to diagnosis

was 17.7 days (range 0–120 days).

The investigations performed were variable and often

dictated by the referring physician. Fifteen patients had

CT and 12 (80%) were positive, revealing features of a

fistula and demonstrating the underlying aetiology

(Fig. 1). Eleven patients had colonoscopy. All of these

patients presented with large bowel symptoms. A fistulous

opening was seen in 6 (55%) patients. In the

remaining cases, when used, colonoscopy revealed or

excluded relevant associated pathologies.

Five patients referred from the urological service with

faecaluria and pneumaturia were administered oral charcoal.

All patients passed charcoal per urethra within 24 h.

Sixteen patients with genitourinary tract symptoms

underwent cystoscopy of which 14 were positive and

successfully revealed the fistulous opening or an area of

inflammation with charcoal passing through. Contrast

radiology was utilized in a limited number of patients

(Table 1, Fig. 2). There was considerable overlap in the

investigations used.

The intestinal origin of the EVF included sigmoid

colon (n ¼ 20), rectum (n ¼ 4), ileum (n ¼ 3),

Table 1 Investigative results.

Investigation

Patients

(n)

Test

positive*

Test

negative_ % positive

CT 15 12 3 80

Endoscopy 11 6 5 55

Oral charcoal 5 5 0 100

Cystoscopy 16 14 2 88

Small bowel

follow-through

5 3 2 60

Gastrograffin enema 2 2 0 100

Barium enema 8 4 4 50

Cystogram 1 1 0 100

*Identified fistulous tract or fistulous opening; _failed to identify

a fistulous tract or opening but did identify a diseased area and

suggested the underlying aetiology.

Figure 1 Axial CT shows an EVF (black arrows) between an

inflammatory sigmoid colon mass and the bladder. Air within the

bladder (white arrow) is consistent with an EVF.

D. Kavanagh et al. Diagnosis and treatment of enterovesical fistulae

_ 2005 Blackwell Publishing Ltd. Colorectal Disease, 7, 286–291 287

descending colon (n ¼ 1), transverse colon (n ¼ 1) and

ascending colon (n ¼ 1). Underlying aetiologies reflected

the intestinal origin and included diverticular disease

(n ¼ 14), colorectal carcinoma (n ¼ 4), Crohn’s disease

(n ¼ 4), pelvic radiotherapy (n ¼ 4), postoperative sepsis

(n ¼ 2), bladder carcinoma (n ¼ 1) and disseminated

malignant melanoma (n ¼ 1).

Five patients were treated conservatively. This group

included one patient with Crohn’s disease and a coexistent

enterocutaneous fistula. This patient initially underwent

a three-month trial of parenteral nutrition,

intravenous antibiotics and nil by mouth. The fistula

persisted and a primary resection of the involved bowel

segment with ileocolic anastomosis was performed. An

additional patient with a coexistent enterocutaneous

fistula related to intra-abdominal sepsis following complicated

in vitro fertilization was treated with parenteral

nutrition, intravenous antibiotics and nil by mouth. This

patient made a successful symptomatic recovery (closure

of the fistula was confirmed by a decreasingly positive oral

charcoal test, which was ultimately negative). The

remaining three patients included one patient with a

fistula complicating diverticular disease, one fistula related

to advanced malignant melanoma and an additional

patient with a fistula related to radiotherapy for colorectal

carcinoma. The patient with a diverticular-related fistula

was an 81-year-old female who presented with intraabdominal

sepsis. CT scan confirmed the fistula within 24

h and she was treated with intravenous antibiotic therapy.

She had significant cardiac comorbidity and died secondary

to sepsis with acute renal failure. The patient with a

fistula secondary to advanced malignant melanoma was

92 years old. She was treated with oral antibiotics and red

cell transfusions. She eventually succumbed to her

malignancy with persistent fistula-related symptoms.

The final patient treated conservatively was a 54-yearold

who had received previous radiotherapy for colorectal

carcinoma and had an existing colostomy. He described

the passage of urine per rectum. He was treated with oral

antibiotics and died six months later due to disease

progression.

The remaining 25 patients were treated surgically

(Table 2). The underlying aetiologies of these fistulae

included diverticular disease (n ¼ 13), colorectal carcinoma

(n ¼ 4), Crohn’s disease (n ¼ 3), pelvic radiotherapy

(n ¼ 3), sepsis post radical retropubic

prostactectomy (n ¼ 1) and bladder carcinoma (n ¼ 1).

Surgical procedures included primary resection of the

diseased segment with primary anastomosis (n ¼ 12, one

patient had an additional proximal defunctioning loop

ileostomy to avoid pelvic sepsis related to anastomotic

breakdown), Hartmann’s procedure (n ¼ 9), defunctioning

ileostomy (n ¼ 2), defunctioning transverse colostomy

(n ¼ 1) and defunctioning laparoscopic sigmoid

colostomy (n ¼ 1). The management of the bladder

defect involved excision of a cuff of bladder en bloc.

In the diverticular disease group (n ¼ 14), of those

treated surgically 10 patients underwent resection and

primary anastomoses (mean age ¼ 63.7 years) and 3

patients underwent Hartmann’s procedure (mean age ¼

81 years). The latter group had significant intra-abdominal

sepsis at the time of surgery. They also had significant

comorbidities including diabetes (n ¼ 2) and ischaemic

heart disease (n ¼ 1). As a result, resection with primary

anastomosis was deemed inappropriate.

Six patients developed postoperative complications.

General complications included acute renal failure (n ¼

1), acute pulmonary oedema (n ¼ 1) and atrial fibrillation

n ¼ (1). Specific complications included incisional

hernia (n ¼ 1), wound infection (n ¼ 1) and

anastomotic leak (n ¼ 1). There were two peri-operative

deaths (see Table 3). One surgically treated patient

had a recurrence of symptoms (Table 3; patient 1).

This 45-year-old male had an elective sigmoid colectomy

for a diverticular-related fistula. He developed an

anastomotic leak, which was treated nonoperatively

with intravenous nutrition and antibiotic therapy. His

symptoms of faecaluria and pneumaturia returned at

three months and he had a loop ileostomy performed.

This was reversed at four months and he remained

symptom-free at 12 months. A further four patients

died due to progression of the underlying malignancy

but no further fistula-related symptoms were experienced

following surgery. Surgery provided symptomatic

relief in the majority (22 ⁄ 25) of patients (Table 2).

The mean inpatient stay was 29.4 days (range 10–

90 days).

Figure 2 Single contrast cystogram shows an EVF (black arrow)

into the sigmoid colon (arrow heads).

Diagnosis and treatment of enterovesical fistulae D. Kavanagh et al.

288 _ 2005 Blackwell Publishing Ltd. Colorectal Disease, 7, 286–291

Table 2 Patients treated surgically – indications, procedure, outcome.

Sex Age Aetiology Procedure Outcome

Male 45 Diverticular disease Sigmoid colectomy Recurrence at 3 months

Female 59 Diverticular disease Sigmoid colectomy Resolution

Male 68 Diverticular disease Sigmoid colectomy Resolution

Male 87 Colonic carcinoma Sigmoid colectomy Resolution

Male 67 Diverticular disease Sigmoid colectomy Resolution

Female 76 Pelvic radiotherapy Loop colostomy Resolution. Died at 10 months

due to advanced malignancy

Female 69 Bladder carcinoma Loop ileostomy Resolution

Male 78 Diverticular disease Sigmoid colectomy Resolution

Male 59 Diverticular disease Sigmoid colectomy Resolution

Female 79 Diverticular disease Sigmoid colectomy* Postoperative mortality

Male 80 Diverticular disease Sigmoid colectomy Resolution

Female 54 Crohn’s disease Sigmoid colectomy Resolution

Female 68 Pelvic radiotherapy Hartmann’s procedure Resolution

Female 76 Colonic carcinoma Hartmann’s procedure Resolution. Died at 6 months

due to advanced malignancy

Male 52 Colonic carcinoma Hartmann’s procedure Resolution. Died at 8 months

due to advanced malignancy

Female 90 Diverticular disease Hartmann’s procedure Postoperative mortality

Female 62 Diverticular disease Sigmoid colectomy Resolution

Male 53 Post radical prostatectomy Laparoscopic colostomy Resolution. Died at 16 months

due to advanced malignancy

Male 50 Crohn’s disease Hartmann’s procedure Resolution

Female 42 Pelvic radiotherapy Loop ileostomy Resolution

Female 65 Crohn’s disease Hartmann’s procedure Resolution

Female 72 Diverticular disease Hartmann’s procedure Postoperative mortality

Male 81 Diverticular disease Hartmann’s procedure Postoperative mortality

Male 77 Colorectal carcinoma Hartmann’s procedure Resolution

Male 61 Diverticular disease Sigmoid colectomy Resolution

*Had defunctioning loop ileostomy to prevent pelvic sepsis related to anastomotic leak.

Table 3 Clinical and biochemical features of patients with surgical-related morbidity and mortality.

Sex

Age

(years) Comorbidity

Albumin

(g ⁄ dl)

Serum

creatinine

(mmol ⁄ l)

Body

mass index

(kg ⁄ m2)

Morbidity and

mortality

Inpatient

stay

(days)

Male 45 Complex diverticular disease, Diabetes 37 52 23 Anastomotic leak 21

Male 68 Complex diverticular disease 34 47 27 Wound infection 15

Male 80 Complex diverticular disease 29 53 31 Incisional hernia 26

Female 68 Previous radiotherapy, Diabetes 27 57 27 Acute renal failure 45

Female 72 Complex diverticular disease

Ischaemic heart disease

29 42 21 Pulmonary oedema 45

Female 65 Crohn’s disease with perineal sepsis

Ischaemic heart disease

23 57 23 Atrial fibrillation 90

Female 79 Urosepsis, Diabetes.

Complex diverticular disease

26 210 21 Died following

cardio-respiratory arrest

22

Female 90 Incarcerated spigelian hernia

Complex diverticular disease

21 250 22 Died due to multiorgan

failure

15

*Reference values: Serum creatinine 53–97 lmol ⁄ l; Serum albumin 35–50 g ⁄ l.

D. Kavanagh et al. Diagnosis and treatment of enterovesical fistulae

_ 2005 Blackwell Publishing Ltd. Colorectal Disease, 7, 286–291 289

Discussion

‘W.T aged 30 requires to pass urine nearly every quarter

of an hour, and after the urine is passed flatus often

escapes with considerable noise. The urine varies in

character; it is generally turbid, having abundant

yellowish granular precipitate, with faecal odour. Under

the microscope the deposit is seen to consist of pus cells,

vegetable fibbers and granular debris’ [2].

Enterovesical fistula are recognized as a distinct

clinical entity. Rufus of Ephesus first described them in

200 AD as a patient passing urine per rectum. Cripps first

depicted them in the medical literature over a century ago

[2]. This description defines the pathognomonic features

of faecaluria, pneumaturia and recurrent urinary tract

infections. Contrary to classical teaching, in our series

only 50% of patients demonstrated one or more of these

features. There is a distinct preponderance of males

afflicted by this condition with three times more males

than females being affected. The position of the uterus

between the bladder and the sigmoid colon is thought to

be a protective factor in females [9]. Nine female patients

in our series had a previous hysterectomy perhaps

explaining the atypical gender distribution (16 of 30

were female).

The investigative modalities utilized were tailored to

the specific clinical scenario and had variable diagnostic

yield. No single investigation provided convincing evidence

of a fistula in all cases. In our experience patients’

with urinary symptoms referred from the urological

service underwent cystoscopy (n ¼ 16:% positivity ¼

87.5%) with or without the oral charcoal test (n ¼ 5:%

positivity ¼ 100%) [10]. Cystoscopy has been repeatedly

reported as the most accurate diagnostic modality and

some advocates recommend it as the first line investigation

[11].

Alternatively, those presenting with altered bowel

habit underwent endoscopy or contrast enema with

variable diagnostic yield when employed (n ¼ 11:%

positivity ¼ 54.5%). CT scanning was positive in 80% of

cases and suggested the underlying aetiology in the

remainder of cases. The use of CT with oral contrast has

been advocated particularly for use in the evaluation of

enterovesical fistulae particularly before bladder instrumentation

[12].

We recommend colonic evaluation in all cases prior to

surgery. Cystoscopic evaluation should be performed in

all patients with genitourinary symptoms. We recommend

CT for further evaluation of the underlying

aetiology and to facilitate surgical planning.

The aetiologies in our series differ from published

data with almost half of the patients developing EVF

from diverticular disease [6]. Enterovesical fistulae

rarely close spontaneously and surgery is generally

required [13]. It is recognized that without surgical

intervention 75% of patients may die from sepsis within

5 years [14,15]. In our experience despite the small

numbers treated nonoperatively and a heterogenous

group of patients with variable comorbidity, surgery

provided the optimum mode of therapy.

(Table 2) These data mirror other published findings

[6,7,11,16].

When conditions were suitable a colonic resection

with primary anastomoses was performed (12 ⁄ 25). This

procedure was associated with one anastomotic breakdown

(fistula-related symptoms recurred at 3 months)

and one peri-operative mortality. The latter had an

upstream diverting loop ileostomy. Others similarly

recommend a single stage procedure with primary anastomosis

when it is feasible [17,18]. Some advocate an

upstream diverting loop ileostomy if there is any question

about the integrity of the anastomoses. They propose

that these are easily reversed and laparotomy is rarely

indicated unlike the reversal of a Hartmann’s procedure

[19,20]. Nine patients had a Hartmann’s procedure.

There was one peri-operative death. A further three

patients developed general postoperative complications.

This was the preferred procedure in the setting of intraabdominal

sepsis and poor performance status [8]. This

procedure successfully alleviated symptoms in each case.

In selected cases a defunctioning stoma was performed

where curative resection of the underlying cause was not

possible.

Conclusion

Classical urinary symptoms were only evident in 50% of

patients. The majority of these are related to complex

diverticular disease. All patients who present with genitourinary

symptoms should have a cystoscopy. All

patients undergoing fistula-related bowel surgery should

have a pre-operative colonic evaluation. CT is the

optimum imaging modality to diagnose the fistula and

delineate the extent of the underlying disease process.

The surgical intervention performed in each case was

individualized based on pre-operative performance status

and the presence or absence of intra-abdominal sepsis.

When a combined surgical approach is employed encompassing

both the coloproctologist and the urologist,

surgical management offers the most effective method of

management.

 

Penulis: Buletin Jum’at Al-Atsariyyah

Banyak diantara agama, dan sunnah Nabi -Shollallahu ‘alaihi wasallam- yang dilalaikan orang pada hari ini sehingga terkadang menjadi sesuatu yang mahjur (ditinggalkan).

Inilah yang pernah diisyaratkan oleh Nabi -Shallallahu ‘alaihi wa sallam- ketika beliau bersabda dalam sebuah hadits,

بَدَأَ الْإِسْلَامُ غَرِيْبًا وَسَيَعُوْدُ كَمَا بَدَأَ غَرِيْبًا فَطُوْبَى لِلْغُرَبَاءِ

“Islam muncul dalam keadaan asing, dan akan kembali (asing), sebagaimana ia muncul dalam keadaan asing. Maka beruntunglah orang-orang asing”. [HR. Muslim dalam Kitab Al-Iman (232)]

Semua ini disebabkan karena kurangnya perhatian kaum muslimin terhadap agamanya dan sunnah Rasul-Nya-shollallahu alaihi wasallam-. Kurangnya perhatian mereka menuntut ilmu syar’i karena kesibukan duniawi yang memalingkan mereka. Sementara mereka tak ada perhatian lagi dengan majelis ilmu dan majelis ta’lim. Akibatnya, agama dan Sunnah Nabi -Shallallahu ‘alaihi wa sallam- terasa asing dan aneh di sisi mereka.

Memang mereka terkadang mendatangi majelis ta’lim. Namun jika mereka hadir, nampak pada wajah mereka lelah dan keterpaksaan ikut majelis ta’lim. Yah, hanya sekedar hadir agar orang tidak mencelanya. Maka anda akan lihat orang semacam ini jika hadir di majelis ta’lim, ada yang ngantuk , bahkan tidur. Ada yang bersandar di tembok, jauh dari ustadz. Ada yang sengaja duduk di belakang untuk sembunyi; jika ngantuk dan tertidur, ia bisa sembunyikan wajahnya di balik punggung kawannya. Ada yang cerita dengan temannya sehingga mengganggu ceramah ustadz. Ada yang melayang pikirannya sampai Amerika. Inilah kondisi mereka sehingga tak heran jika mereka tetap jahil terhadap agamanya.

Jika mendengar cerita yang menguntungkan dunianya, maka matanya terbelalak. Betul dunia adalah nikmat yang Allah berikan. Namun jangan dijadikan tujuan hidup dan pusat perhatian. Dunia diambil sekedar bekal menuju Allah -Ta’ala-. Allah tidak memberikan nikmat kepada seorang hamba-Nya, kecuali nikmat itu hanya sekedar alat dan sarana yang dipakai untuk beribadah dan beramal sholeh. Dunia dengan segala nikmatnya bukanlah merupakan tujuan dan terminal terakhir bagi seorang muslim. Akan tetapi merupakan tempat persinggahan mengambil bekal menuju perjalanan akhir, yaitu akhirat.

Fenomena berlombanya kaum muslimin memperbanyak harta benda dan fasilitas duniawi sehingga membuat mereka lupa terhadap agamanya merupakan sebab tersebarnya kejahilan. Jika semakin hari, semakin tersebar kejahilan, maka ketahuilah bahwa ini adalah salah satu diantara ciri dan tanda dekatnya hari kiamat.

Nabi-shollallahu alaihi wasallam- bersabda,

مِنْ أَشْرَاطِ السَّاعَةِ : أَنْ يُرْفَعَ الْعِلْمُ وَ يُثْبَتَ الْجَهْلُ

“Diantara tanda-tanda kiamat: Diangkatnya ilmu, dan kokohnya (banyaknya) kejahilan”. [HR. Al-Bukhoriy dalam Shohih-nya (80), dan Muslim dalam Shohih-nya (2671)]

Di akhir zaman, seperti zaman kita ini, sebelum datangnya hari kiamat akan ada hari-hari yang di dalamnya turun dan tersebar kejahilan yang disebabkan oleh malasnya manusia dan enggannya mereka dari menuntut ilmu agama, yaitu ilmu tentang Al-Qur’an dan Sunnah. Nabi-shollallahu alaihi wasallam- bersabda,

إِنَّ بَيْنَ يَدَيِ السَّاعَةِ لَأَيَّامًا يَنْزِلُ فِيْهَا الْجَهْلُ وَيُرْفَعُ الْعِلْمُ

“Sesungguhnya di depan hari kiamat ada hari-hari yang kejahilan diturunkan di dalamnya, dan ilmu diangkat”. [HR. Al-Bukhoriy (6654)]

Di tengah kabut kejahilan menyelimuti manusia, tersebarlah berbagai macam maksiat berupa pembunuhan, pencurian, perzinaan, dan kerakusan terhadap harta. Ini semua diakibatkan oleh hilangnya ilmu agama yang bermanfaat di tengah manusia. Nabi-shollallahu alaihi wasallam- bersabda dalam riwayat lain ketika menyebutkan tanda dekatnya hari kiamat,

يَتَقَارَبُ الزَّمَانُ وَيُقْبَضُ الْعِلْمُ وَتَظْهَرُ الْفِتَنُ وَيُلْقَى الشُّحُّ وَيَكْثُُرُ الْهَرْجُ

“Zaman akan saling mendekat, diangkatnya ilmu, munculnya berbagai fitnah (masalah), diletakkan kerakusan, dan banyaknya peperangan”. [HR. Al-Bukhoriy (989) dan Muslim (157)]

Al-Imam Ibnu Baththol –rahimahullah- berkata , “Semua yang dikandung oleh hadits ini berupa tanda-tanda kiamat sungguh kami telah melihatnya dengan mata kepala. Ilmu sungguh telah diangkat, kejahilan muncul, dile tak kannya penyakit rakus dalam hati, fitnah (musibah) merata, dan pembunuhan banyak”. [Lihat Fath Al-Bari (13/16)]

Ini di zamannya Ibnu Baththol –rahimahullah-, maka bagaimana lagi di zaman kita ini kejahilan merata dimana-mana, baik di kota maupun di pedalaman. Kejahilan di negeri kita bukan hanya mengenai rakyat jelata yang tak berpendidikan agama, bahkan juga mengenai kaum terpelajar. Hal ini sebagaimana yang disabdakan oleh Nabi-shollallahu alaihi wasallam-,

إِنَّ اللهَ لَا يَقْبِضُ الْعِلْمَ اِنْتِزَاعًا يَنْتَزِعُهُ مِنَ النَّاسِ وَلَكِنْ يَقْبِضُ الْعِلْمَ بِقَبْضِ الْعُلَمَاءِ حَتَّى إِذَا لَمْ يَتْرُكْ عَالِمًا اِتَّخَذَ النَّاسُ رُؤُسًا جُهَّالًا فُسُئِلُوْا فَأَفْتَوْا بِغَيْرِ عِلْمٍ فَضَلُّوْا وَأَضَلُّوْا

“Sesungguhnya Allah tidak mengangkat ilmu dengan sekali mencabutnya dari manusia. Akan tetapi Allah mencabut ilmu dengan mematikan para ulama’ sehingga apabila Allah tidak menyisakan lagi seorang ulama’pun, maka manusiapun mengangkat pemimpin-pemimpin yang jahil. Mereka (para pemimpin tsb) ditanyai, lalu merekapun memberikan fatwa tanpa ilmu. Akhirnya mereka sesat dan menyesatkan (manusia)” .[HR.Al-Bukhory dalam Kitab Al-Ilm (100), dan Muslim dalam Kitab Al-Ilm (2673)]

Al-Imam Abu Zakariya An-Nawawiy-rahimahullah- berkata ketika menjelaskan makna hadits di atas, “Hadits ini menjelaskan maksud tercabutnya ilmu dalam hadits-hadits lalu yang muthlak (umum), bukan menghapusnya dari dada para penghafal (pemilik) ilmu itu. Akan tetapi maknanya, para pembawa ilmu itu (yakni para ulama) akan mati. Lalu manusia mengangkat orang-orang jahil (sebagai pemimpin dalam agama). Orang-orang jahil itu memutuskan perkara berdasarkan kejahilan-kejahilannya. Lantaran itu ia sesat, dan menyesatkan orang”. [Lihat Al-Minhaj Syarh Shohih Muslim ibn Al-Hajjaj (16/224), cet. Dar Ihya’ At-Turots Al-Arabiy]

Alangkah banyaknya pemimpin dan ustadz-ustadz seperti ini. Mereka diangkat oleh manusia sebagai seorang ulama’ dan ustadz. Padahal ia tidaklah pantas dijadikan panutan, karena ia jahil. Kalaupun ia berilmu, namun ilmu itu di buang di belakang punggungnya. Manusia jenis ini banyak bermunculan bagaikan jamur di musim hujan.

Coba lihat disana, manusia mengangkat seorang pelawak sebagai “da’i sejuta ummat”. Padahal bisanya cuma tertawa dan menggelitik para pendengar.

Dari arah lain, muncul para normal yang dulunya dijauhi oleh manusia, karena dikenal memiliki sihir. Sesaat kemudian berubah menjadi “da’i sejuta ummat”, karena sekedar pernah memimpin dzikir jama’ah yang dihadiri oleh sebagian kiyai jahil dan orang-orang yang memiliki kedudukan. Dulunya tukang sihir dan dukun (para normal), kini menjadi ustadz, bahkan terakhir bergelar “KH”.

Artis pun tak ketinggalan ambil job dalam kancah dakwah dengan bermodalkan semangat kemampuan tampil di depan publik dan wajah ganteng sebagai modal dengkul untuk menarik ummat menuju ke neraka. Bagaimana tidak, sebab seorang yang berdakwah tanpa ilmu akan mengantarkan dirinya berbicara tanpa batas, sehingga terkadang ia telah merusak dan menghancurkan agama pendengarnya, namun ia tak sadar karena memandang dirinya lebih pandai dari pendengar. Padahal ia jahil atau mungkin lebih jahil dari pendengar. Nas’alullahal afiyah wassalamah minal fitan.

Lebih para lagi, jika dakwah yang ditangani oleh orang-orang jahil dihiasi dengan perkara-perkara yang melanggar syari’at, seperti dakwah dihiasi dengan musik dengan istilah “Nada dan Dakwah”. Ini adalah cara dakwah yang keliru, karena menyalahi tuntunan Nabi -Shallallahu ‘alaihi wa sallam- . Dengarkan Nabi -Shallallahu ‘alaihi wa sallam- bersabda dalam mengharamkan musik,

لَيَكُوْنَنَّ مِنْ أُمَّتِيْ أَقْوَامٌ يَسْتَحِلُّوْنِ الْحِرَّ وَالْحَرِيْرَ وَالْخَمْرَ وَالْمَعَازِفَ

“Sesungguhnya akan ada beberapa kaum dari ummatku akan menghalalkan zina, kain sutra, minuman keras (khomer), dan musik”. [HR. Al-Bukhoriy dalam Kitab Al-Asyribah (5590)]

Muhaddits Negeri Syam Muhammad Nashiruddin Al-Albaniy Al-Atsariy –rahimahullah- berkata dalam kitabnya Tahrim Alat Ath-Thorb (hal 105), “Sesungguhnya para ulama dan fuqoha –diantaranya empat imam madzhab- sepakat mengharamkan alat-alat musik karena berteladan dengan hadits-hadits Nabi Shollallahu Alaihi wa Sallam dan atsar-atsar Salaf ”.

Jadi, berdakwah dengan musik merupakan perkara kejahilan dan kebatilan yang menyalahi tuntunan Allah -Ta’ala-, Nabi -Shallallahu ‘alaihi wa sallam- , dan para ulama’ kaum msulimin dari dulu sampai hari ini. Oleh karena itu, kita sesalkan adanya sebagian orang-orang jahil atau pura-pura jahil yang menyemarakkan program “Nada dan Dakwah” yang jelas dan nyata menyelihi agama !! Ini lebih diperparah lagi dengan bantuan “Guru Besar” alias televisi dalam menyemarakkannya demi meraih keuntungan duniawi yang semu, dan memperturutkan hawa nafsu.

Realita ummat yang demikian ini membuat dahi berkerut dan kepala sakit karena banyaknya dan bertambahnya “PR” yang perlu diselesaikan oleh para dai kebenaran. Dengan realita kejahilan ummat seperti ini, tak pelak jika banyak menimbulkan masalah. Tak heran jika terkadang ada sunnah Nabi -Shollallahu ‘alaihi wasallam- yang ingin diamalkan di zaman ini, mereka serta merta merasakannya sebagai suatu yang asing, menolaknya, menganggapnya bukan dari Islam!! Bahkan memusihi dan menyakiti sebagian hamba-hamba Allah -Ta’ala- yang mengamalkannya.

Jika kejahilan tentang agama merata di tubuh ummat, maka akan tersebar berbagai macam pelanggaran, syirik, kekafiran, bid’ah, dan maksiat, baik yang nampak, maupun yang tersemunyi. Inilah awal kehinaan yang akan menimpa ummat Islam yang dimanfaatkan oleh musuh-musuh Islam.

Jika ummat Islam sibuk dengan dunia, sibuk dengan peternakan, pertanian, perdagangan –apalagi riba- sehingga lupa mempelajari agamanya dari Al-Qur’an dan Sunnah, maka Allah akan timpakan kehinaan atas mereka. Inilah kehinaan yang tak mungkin akan tercabut dari tubuh ummat kecuali mereka mau kembali kepada agamanya dengan ilmu agama yang benar, dan berguna.

Nabi -Shallallahu ‘alaihi wa sallam- bersabda,

إِذَا تَبَايَعْتُمْ بِالْعِيْنَةِ وَأَخَذْتُمْ أَذْنَابَ الْبَقَرِ وَرَضِيْتُمْ بِالزَّرْعِ وَتَرَكْتُمُ الْجِهَادَ سَلَّطَ اللهُ عَلَيْكُمْ ذُلًّا لَا يَنْزِعُهُ حَتَّى تَرْجِعُوْا إِلَى دِيْنِكُمْ

“Jika kalian berjual-beli dengan cara ‘inah (salah satu bentuk riba, -pen), kalian memegang ekor-ekor sapi, ridho dengan bercocok tanam, dan meninggalkan jihad, maka Allah akan menimpakan kepada kalian suatu kehinaan yang tak akan dicabut oleh Allah sampai kalian kembali kepada agama kalian”. [HR. Abu Dawud dalam Sunan-nya (3462). Hadits ini di-shohih-kan oleh Al-Muhaddits Al-Atsariy Syaikh Al-Albaniy dalam Ash-Shohihah (11)]

Kesibukan dengan dunia menyebabkan kita akan semakin cinta kepadanya, dan takut mati untuk menghadap Allah -Ta’ala- .Seakan-akan kita mengharapkan diri dan harta benda yang melalaikan kita agar kekal di dunia, tanpa menghadapi hisab.

Abu Hurairah -radhiyallahu ‘anhu- berkata, Rasulullah -Shallallahu ‘alaihi wa sallam- bersabda,

يُوْشِكُ الْأُمَمُ أَنْ تَدَاعَى عَلَيْكُمْ كَمَا تَدَاعَى الْأَكَلَةُ إِلَى قَصْعَتِهَا فَقَالَ قَائِلٌ: وَمِنْ قِلَّةٍ نَحْنُ يَوْمَئِذٍ ؟ قَالَ : بَلْ أَنْتُمْ يَوْمَئِذٍ كَثِيْرٌ وَلَكِنَّكُمْ غُثَاءٌ كَغُثَاءِ السَّيْلِ وَلَيَنْزِعَنَّ اللهُ مِنْ صُدُوْرِ عَدَوِّكُمْ الْمَهَابَةَ مِنْكُمْ وَلَيَقْذِفَنَّ اللهُ فِيْ قُلُوْبِكُمْ الْوَهْنَ ” فَقَالَ قَائِلٌ: يَارَسُوْلَ اللهِ وَمَا الْوَهْنُ ؟ قَالَ : حُبُّ الدُّنْيَا وَكَرَاهِيَةُ الْمَوْتِ

“Hampir saja ummat-ummat saling memanggil (menyerang) menuju kalian sebagaimana orang-orang yang mau makan saling memanggil kepada nampannya”. Ada yang bertanya, “Apakah karena kita sedikit saat itu?” Beliau bersabda, “Bahkan kalian saat itu banyak, tapi kalian buih laksana buih ombak. Allah benar-benar akan mencabut perasaan segan terhadap kalian dari dada musuh kalian; Allah akan mencampakkan kelemahan dalam hati kalian”. Ada yang bertanya, “Apa kelemahan itu?” Beliau menjawab, “Cinta dunia, dan takut mati”.[HR. Abu Dawud dalam Kitab Al-Malahim (4297). Di-shohih-kan oleh Al-Albaniy dalam Ash-Shohihah (958)]

Sumber : Buletin Jum’at Al-Atsariyyah edisi 60 Tahun I. Penerbit : Pustaka Ibnu Abbas. Alamat : Pesantren Tanwirus Sunnah, Jl. Bonto Te’ne No. 58, Kel. Borong Loe, Kec. Bonto Marannu, Gowa-Sulsel. HP : 08124173512 (a/n Ust. Abu Fa’izah). Pimpinan Redaksi/Penanggung Jawab : Ust. Abu Fa’izah Abdul Qadir Al Atsary, Lc. Dewan Redaksi : Santri Ma’had Tanwirus Sunnah – Gowa. Editor/Pengasuh : Ust. Abu Fa’izah Abdul Qadir Al Atsary, Lc. Layout : Abu Dzikro. Untuk berlangganan/pemesanan hubungi : Ilham Al-Atsary (085255974201). (infaq Rp. 200,-/exp

http://almakassari.com/?p=261

by : Marsudi Fitro Wibowo

Harian Umum Pikiran Rakyat (PR) Bandung
Halaman 14, Selasa (Kliwon) 03 Februari 2004

TENTU kita masih ingat akan sejarah kedatangan Thariq bin Ziyad bersama pasukannya pada bulan Mei tahun 711 M memasuki selat Gibraltar yang terletak di teluk Algeciras, sebagai cikal bakal perkembangan kebudayaan Islam dan kerajaan-kerajaan Islam yang mulai bercokol di tanah Andalusia (sekarang Spanyol). Berkat kedatangan Islam di Andalusia hampir delapan abad lamanya kaum Muslim mengusasi kota-kota penting seperti Toledo, Saragosa, Cordoba, Valencia, Malaga, Seville, Granada dan lain sebagainya, mereka membawa panji-panji ke-Islaman, baik dari segi Ilmu pengetahuan, Kebudayaan, maupun segi Arsitektur bangunan.

Di negeri inilah lahir tokoh-tokoh muslim ternama yang menguasai berbagai ilmu pengetahuan, seperti Ilmu Agama Islam, Kedokteran, Filsafat, Ilmu Hayat, Ilmu Hisab, Ilmu Hukum, Sastra, Ilmu Alam, Astronomi, dan lain sebagainya. Oleh karena itu dengan segala kemajuan dalam berbagai ilmu pengetahuan, kebudayaan serta aspek-aspek ke-islaman, Andalusia kala itu boleh dikatakan sebagai pusat kebudayaan Islam dan Ilmu Pengetahuan yang tiada tandingannya setelah Konstantinopel dan Bagdad. Maka tak heran waktu itu pula bangsa-bangsa Eropa lainnya mulai berdatangan ke negeri Andalusia ini untuk mempelajari berbagai Ilmu pengetahuan dari orang-orang Muslim Spanyol, dengan mempelejari buku-buku buah karya cendekiawan Andalusia baik secara sembunyi-sembunyi ataupun terang-terangan.

Diantara cendekiawan-cendekiawan asal andalusia tercatat Ibnu Thufail (1107-1185) dilahirkan di Asya, Granada. Nama lengkapnya adalah Abu Bakr Muhammad ibn Abdul Malik ibn Muhammad ibn Muhammad ibn Thufail al-Qisi, ia pernah menjabat sebagai Mentri dalam bidang Politik di pemerintahan, dan juga pernah sebagai Gubernur untuk Wilayah Sabtah dan Tonjah di Magribi. Sebagai ahli falsafah, Ibnu Thufail adalah guru dari Ibnu Rusyd (Averroes), ia mengusai ilmu lainnya seperti ilmu hukum, pendidikan, dan kedokteran, sehingga Thufail pernah menjadi sebagai dokter pribadi Abu Ya’kub Yusuf seorang Amirul Muwahhidin. Ibnu Thufail atau di kenal pula dengan lidah Eropa sebagai Abubacer menulis Roman Filasafat dalam literatur abad pertengahan dengan nama Kitabnya “Hayy ibn Yaqzan”, salah satu buku sebagai warisan dari ahli filsafat Islam tempo dulu yang sampai kepada kita, sedangkan sebagian karyanya hilang.

Al-Idrisi, lahir di Ceuta pada tahun 1100 M salah seorang ahli Geografi dengan nama lengkapnya Abu Abadallah Muhammad al-Idrisi, yang menulis Kitab Ar-Rujari atau dikenal dengan Buku Roger salah satu buku yang menjelaskan tentang peta dunia terlengkap, akurat, serta menerangkan pembagian-pembagian zona iklim di dunia. Ar-Rujari sebuah karya yang diperbantukan untuk Raja Roger II, dimana buku ini sempat dimanfaatkan oleh orang-orang Eropa baik Muslim maupun non Muslim. Al-Idrisi adalah seorang yang tekun, pekerja keras dan tanpa lelah untuk mengerjakan sesuatu yang bermanfaat, ia menggali ilmu Geografi dan ilmu Botani di Kordoba Spanyol. Selain itu dalam melahirkan ahli Botani, Andalusia mencatat pula nama Abu Muhammad ibn Baitar atau Ibnu Baitar (1190-1248) yang dilahirkan di Malaga, dialah yang petama kali menggabungkan ilmu-ilmu botani Islam, dimana karyanya dijadikan sebagai standar referensi hingga abad ke-16.

Ibnu Bajjah (1082-1138), ia dilahirkan di Saragosa dengan nama lengkapnya Abu Bakr Muhammad Ibn Yahya al-Saigh, ia adalah seorang yang cerdas sebagai ahli matematika, fisika, astronomi, kedokteran, filsafat, dan penyair dari golongan Murabitin, selain hafal Al-Qur’an beliaupun piawai dalam bermain musik gambus. Kepercayaanya terhadap Ibnu Bajjah dalam bermain politik semasa kepemimpinan Abu Bakr Ibrahim ia diangkat menjadi Mentri di Saragosa. Karangannya yang terkenal adalah an-Nafs (Jiwa) yang menguraikan tentang keadaan jiwa yang terpengaruhi oleh filsafat Aristoles, Galenos, al-Farabi, dan Ar-Razi. Dalam usia 56 tahun Ibnu Bajjah meninggal sebab diracuni dan hasil karyanya banyak yang dimusnahkan, namun ajaran-ajarannya mempengaruhi para ilmuwan berikutnya di tanah Andalusia.

Ibnu Rusyd (1126-1198) lahir di Cordova lidah barat menyebutnya Averroes yang nama lengkapnya adalah Abdul Walid Muhammad bin Ahmad bin Muhammad Ibnu Rusyd. Ibnu Rusyd adalah seorang ahli hukum, ilmu hisab (arithmatic), kedokteran, dan ahli filsafat terbesar dalam sejarah Islam dimana ia sempat berguru kepada Ibnu Zuhr, Ibn Thufail, dan Abu Ja’far Harun dari Truxillo. Pada tahun 1169 Ibn Rusyd dilantik sebagai hakim di Sevilla, pada tahun 1171 dilantik menjadi hakim di Cordova. Karena kepiawaiannya dalam bidang kedokteran Ibnu Rusyd diangkat menjadi dokter istana tahun 1182.

Karya besar yang di tulis oleh Ibnu Rusyd adalah Kitab Kuliyah fith-Thibb (Encyclopaedia of Medicine) yang terdiri dari 16 jilid, yang pernah di terjemahkan kedalam bahasa Latin pada tahun 1255 oleh seorang Yahudi bernama Bonacosa, kemudian buku ini diterjemahkan kedalam bahasa Inggris dengan nama “General Rules of Medicine” sebuah buku wajib di universitas-universitas di Eropa. Karya lainnya Mabadil Falsafah (pengantar ilmu falsafah), Taslul, Kasyful Adillah, Tahafatul Tahafut, Bidayah al-Mujtahid wa Nihayah al-Muqtashid, Tafsir Urjuza (menguraikan tentang pengobatan dan ilmu kalam), sedangkan dalam bidang musik Ibnu Rusyd telah menulis buku yang berjudul “De Anima Aristotles” (Commentary on the Aristotles De Animo). Ibnu Rusyd telah berhasil menterjemahan buku-buku karya Aristoteles (384-322 SM) sehingga beliau dijuluki sebagai asy-Syarih (comentator) berkat Ibnu Rusyd-lah karya-karya Aristoteles dunia dapat menikmatinya. Selain itu beliaupun mengomentari buku-buku Plato (429-347 SM), Nicolaus, Al-Farabi (874-950), dan Ibnu Sina (980-1037).

Ibnu Rusyd seorang yang cerdas dan berfikiran kedepan sempat dituduh sebagai orang Yahudi karena pemikiran-pemikirannya sehingga beliau di asingkan ke Lucena dan sebagian karyanya dimusnahkan. Doktrin Averoism mampu pengaruhi Yahudi dan Kristen, baik barat maupun timur, seperti halnya pengaruhi Maimonides, Voltiare dan Jean Jaques Rousseau, maka boleh dikatakan bahwa Eropah seharusnya berhutang budi pada Ibnu Rusyd.

Ibnu Zuhr (1091-1162) atau Abumeron dikenal pula dengan nama Avenzoar yang lahir di Seville adalah seorang ahli fisika dan kedokteran beliau telah menulis buku “The Method of Preparing Medicines and Diet” yang diterjemahkan kedalam bahasa Yahudi (1280) dan bahasa Latin (1490) sebuah karya yang mampu pengaruhi Eropa dalam bidang kedokteran setelah karya-karya Ibnu Sina Qanun fit thibb atau Canon of Medicine yang terdiri dari delapan belas jilid.

Ibnu Arabi (1164-1240), dikenal juga sebagai Ibnu Suraqah, Ash-Shaikhul Akbar, atau Doktor Maximus yang dilahirkan di Murcia (tenggara Spanyol). Pada usia delapan tahun tepatnya tahun 1172 ia pergi ke Lisbon untuk belajar pendidikan Agama Islam yakni belajar Al-Qur’an dan hukum-hukum Islam dari Syekh Abu Bakar bin Khalaf. Setelah itu ia pergi ke Seville salah satu pusat Sufi di Spanyol, disana ia menetap selama 30 tahun untuk belajar Ilmu Hukum, Theologi Islam, Hadits, dan ilmu-ilmu tashawwuf (Sufi).

Karyanya sungguh luar biasa, konon Ibnu Arabi menulis lebih dari 500 buah buku, sekarang di perpustakaan Kerajaan Mesir di Kairo saja masih tersimpan 150 karya Ibnu Arabi yang masih ada dan utuh. Diantara karya-karyanya adalah Tafsir Al-Qur’an yang terdiri 29 jilid, Muhadaratul Abrar Satu jilid, Futuhat terdiri 20 jilid, Muhadarat 5 jilid, Mawaqi’in Nujum, at-Tadbiratul Ilahiyyah, Risalah al-khalwah, Mahiyyatul Qalb, Mishkatul Anwar, al Futuhat al Makiyyah yakni suatu sistim tasawwuf yang terdiri dari 560 bab dan masih banyak lagi karangan-karangan hasil pemikiran Ibnu Arabi yang mempengaruhi para sarjana dan pemikir baik di Barat maupun Timur setelah kepergiaanya.

Ibnu Arabi dengan nama lengkapnya Syekh Mukhyiddin Muhammad Ibnu ‘Ali adalah salah seorang sahabat dekat Ibnu Rusyd. Ia sering berkelana untuk thalabul ‘ilmi (mencari ilmu) dan mengamalkan ilmu yang dimilikinya seperti ke Maghribi, Cordova, Mesir, Tunisa, Fez, Maroko, Jerussalem, Makkah, Hejaz, Allepo, Asia kecil, dan Damaskus hingga wafatnya disana dan dimakamkan di Gunung Qasiyun.
**

Hampir delapan abad lamanya Islam berkuasa di Andalusia sejak tahun 711 M hingga berakhirnya kekuasaan Islam di Granada pada tanggal 2 Januari 1492 M / 2 Rabiul Awwal 898 H tepatnya 512 tahun lalu, Andalusia dalam masa kejayaan Islam telah melahirkan cendekiawan-cendekiawan muslim yang tertulis dengan tinta emas di sepanjang jaman. Karya mereka yang masih ada banyak diterjemahkan dalam berbagai bahasa di penjuru dunia. Sehingga universitas-universitas dibangun di negeri ini ditengah ancaman musuh-musuhnya.

Itulah keunikan para ulama, cendekiawan-cendekiawan tempo dulu bukan saja menguasai satu bidang ilmu pengetahuan namun mereka menguasai berbagai ilmu pengetahuan yang disegani dan tanpa pamrih, hingga nama mereka dikenang oleh setiap insan. Kini bukti kemajuan akan peradaban Islam tempo dulu di Spanyol dapat kita lihat sisa-sisa bangunan yang penuh sejarah dari Toledo hingga Granada, dari Istana Cordova hingga Alhambra. Dan disinilah berkat kekuasaan Tuhan walaupun kekuasaan Islam di Spanyol telah jatuh kepada umat Kristen beberapa abad silam yang menjadikan Katolik sebagai agama resmi, namun karya-karya anak negeri ini mampu memberikan sumbangsih yang luar biasa bagi umat manusia hingga di abad milenium yang super canggih.

Satu hal yang harus kita renungkan sekarang, apa yang telah engkau berikan kepada bangsa dan umat manusia ini. Kemanfaatan atau Kemadlaratan?.

ABSTRACT

Sumono Nurhadi Putranto, G0004205, The Relationship Between Emotional Quotient (EQ) With Anxiety at Batch 2006 of medical students of Medical Faculty of Sebelas Maret University, Medical Faculty of Sebelas Maret University.

Emotional Quotient is ability to recognize and manage our own feelings to make a good social interaction and we have capability to solve demand and stress from our environment. Anxiety is one kind of fear that thought something bad will be happened to himself. Anxiety is response to threat, but anxiety become abnormal response if the intensity of threat is not proportional with the real threat.

The aim of this research is to prove the relationship of Emotional Quotient With Anxiety, where someone has high emotional quotient score means that he could manage himself motivation, and manage his feelings so he is not easy to get anxiety. Thus very important to find a solution on how to manage anxiety by optimize emotional quotient.

This is a cross sectional research with descriptive analytic approach using the population from batch 2006 medical students, about 129 students are valid to be analyzed as a subject of research. The research conducted using L-MMPI, EQ inventory scale, and Taylor Manifest Anxiety Scale (T-MAS). The obtained data was analyzed with Product Moment Correlation Test from Pearson using SPSS 16.0 for windows.

Based on analyzed data with the Product Moment Correlation test from Pearson with α = 0,01 and r counted = -0,27 (p = signification value, p = 0,01) and from analyzed we have got p = 0,002, because p counted < p table and -1 < r < 1, we can conclude that we have the significant evident of correlation between Emotional Quotient with Anxiety at batch 2006 of medical students of Sebelas Maret University.

Keywords: Emotional Quotient (EQ) and Anxiety.

Anomali Gaji di Indonesia

Rekan Denny Indrayana, pakar hukum dari UGM dan Ketua Pusat Antikorupsi, pernah melakukan kalkulasi perbandingan gaji pejabat di Indonesia dengan sumber acuan data dari Komite Pemantau Legislatif (KOPEL) Sulawesi Selatan sebagai berikut.

Dari tabel di atas terlihat bahwa dengan implementasi PP No. 37 Tahun 2006 akan memungkinkan seorang Ketua DPRD Provinsi mengantongi setidaknya Rp 36 juta per bulan. Bandingkan dengan guru besar (dekan) yang cuma bisa membawa pulang Rp 5,3 juta per bulan. Padahal untuk menjadi seorang guru besar dibutuhkan pendidikan lanjut dan penelitian serta publikasi ilmiah yang cukup sulit.

Pun bila dibandingkan dengan Anggota DPRD, seorang profesor jelas lebih memberikan banyak kontribusi bagi komunitasnya dan turut berperan serta dalam usaha pencerdasan bangsa. Sementara anggota dewan lebih banyak dikritik karena kompetensi, produk kerja, dan kinerjanya masih perlu dipertanyakan lagi.

Tunjangan Rapelan yang Salah Sasaran

Kalau boleh memilih, saya lebih suka bila tunjangan tersebut dialokasikan ke tempat yang lebih tepat, misalnya untuk buruh dan guru/dosen, atau membiayai sekolah anak miskin.

Guru misalnya. Seharusnya, gaji guru lebih tinggi daripada gaji pegawai adminsitrasi dan industri. Di Amerika, gaji guru lebih tinggi 128% dari gaji orang kantoran. Di Swedia malah lebih tinggi 235%. Dan tak perlu jauh-jauh, gaji guru di Thailand saja 125% lebih tinggi daripada gaji pegawai. Wajar jika melihat beban dan kontribusi yang diembannya.

Sementara di Indonesia, guru golongan IV/a cuma memperoleh sekitar Rp 999.000 (sebelum ada kenaikan) sebulan. Belum lagi ia harus terkena potongan potongan pinjaman, koperasi, dan potongan lain-lain, plus biaya transportasi dan makan saat bertugas. Tak pelak, guru terpaksa nyambi sana-sini untuk menjaga dapur tetap mengepul. Efek dari usaha tersebut, konsentrasi guru terpecah dan hasil belajar siswa kurang memuaskan.

Nasib “agak mendingan” dimiliki oleh guru besar. Dengan take home pay sebesar Rp 2,7 juta per bulan, sebenarnya bisa dibilang cukup berat. Apalagi seorang guru besar harus selalu meng-update pengetahuan yang dimilikinya lewat berlangganan jurnal ilmiah, membeli text-book, mengikuti konferensi/seminar, akses internet, dan sebagainya yang jelas membutuhkan banyak biaya.

Padahal sebenarnya, di tangan merekalah masa depan bangsa ini berada.

Wakil Rakyat = Pelayan Rakyat

Dan ijinkan saya buat menutup tulisan ini dengan mengutip kata-kata ayah saya, bahwa menjadi wakil rakyat adalah komitmen untuk mengabdi dan melayani rakyat. Tentu wakil rakyat harus siap untuk berkorban waktu, tenaga, dan materi demi memenuhi aspirasi rakyat. Jangan jadikan jabatan wakil rakyat untuk menumpuk kekayaan — apalagi kekayaan yang diperoleh dengan menindas rakyat. Justru berkorbanlah buat rakyat supaya mereka juga bisa hidup sejahtera.

Kalau memang ingin kaya, jadilah pengusaha yang baik dan sukses. Karena dengan menjadi pengusaha, Anda tak hanya berdiri di atas kaki sendiri, melainkan juga membantu orang lain untuk berdiri di atas kakinya masing-masing.

Saya sendiri percaya bahwa tak semua wakil rakyat adalah buruk. Banyak juga wakil rakyat yang memiliki hati nurani. Dan sekarang sudah saatnya mereka mulai memikirkan kesejahteraan rakyat, bukannya justru mengambil posisi berseberangan dengan kepentingan rakyat yang diwakilinya.

Amien.

Rahasia di Balik Sakit

Jumat, 15 Februari 2008

Hidup ini tidak lepas dari cobaan dan ujian, bahkan cobaan dan ujian merupakan sunatullah dalam kehidupan. Manusia akan diuji dalam kehidupannya baik dengan perkara yang tidak disukainya atau bisa pula pada perkara yang menyenangkannya. Allah ta’ala berfirman yang artinya, “Tiap-tiap yang berjiwa akan merasakan mati. Kami akan mengujimu dengan keburukan dan kebaikan sebagai cobaan (yang sebenar-benarnya). Dan hanya kepada Kami-lah kamu dikembalikan.” (QS. al-Anbiyaa’: 35). Sahabat Ibnu ‘Abbas -yang diberi keluasan ilmu dalam tafsir al-Qur’an- menafsirkan ayat ini: “Kami akan menguji kalian dengan kesulitan dan kesenangan, kesehatan dan penyakit, kekayaan dan kefakiran, halal dan haram, ketaatan dan kemaksiatan, petunjuk dan kesesatan”. (Tafsir Ibnu Jarir). Dari ayat ini, kita tahu bahwa berbagai macam penyakit juga merupakan bagian dari cobaan Allah yang diberikan kepada hamba-Nya. Namun di balik cobaan ini, terdapat berbagai rahasia/hikmah yang tidak dapat di nalar oleh akal manusia.Sakit menjadi kebaikan bagi seorang muslim jika dia bersabar Rasulullah shallallahu ‘alaihi wa sallam bersabda yang artinya, “Sungguh menakjubkan perkara seorang mukmin, sesungguhnya semua urusannya merupakan kebaikan, dan hal ini tidak terjadi kecuali bagi orang mukmin. Jika dia mendapat kegembiraan, maka dia bersyukur dan itu merupakan kebaikan baginya, dan jika mendapat kesusahan, maka dia bersabar dan ini merupakan kebaikan baginya. (HR. Muslim) Sakit akan menghapuskan dosa Ketahuilah wahai saudaraku, penyakit merupakan sebab pengampunan atas kesalahan-kesalahan yang pernah engkau lakukan dengan hati, pendengaran, penglihatan, lisan dan dengan seluruh anggota tubuhmu. Terkadang penyakit itu juga merupakan hukuman dari dosa yang pernah dilakukan. Sebagaimana firman Allah ta’ala, “Dan apa saja musibah yang menimpamu maka adalah disebabkan oleh perbuatan tanganmu sendiri, dan Allah memaafkan sebagian besar (dari kesalahan-kesalahanmu).” (QS. asy-Syuura: 30). Rasulullah shallallahu ‘alaihi wa sallam bersabda,”Tidaklah menimpa seorang mukmin rasa sakit yang terus menerus, kepayahan, penyakit, dan juga kesedihan, bahkan sampai kesusahan yang menyusahkannya, melainkan akan dihapuskan dengannya dosa-dosanya. (HR. Muslim) Sakit akan Membawa Keselamatan dari Api Neraka Rasulullah shallallahu ‘alaihi wa sallam bersabda yang artinya,” Janganlah kamu mencaci maki penyakit demam, karena sesungguhnya (dengan penyakit itu) Allah akan mengahapuskan dosa-dosa anak Adam sebagaimana tungku api menghilangkan kotoran-kotoran besi. (HR. Muslim). Oleh karena itu, tidak boleh bagi seorang mukmin mencaci maki penyakit yang dideritanya, menggerutu, apalagi sampai berburuk sangka pada Allah dengan musibah sakit yang dideritanya. Bergembiralah wahai saudaraku, sesungguhnya Rasulullah shallallahu ‘alaihi wa sallam bersabda, “Sakit demam itu menjauhkan setiap orang mukmin dari api Neraka.” (HR. Al Bazzar, shohih) Sakit akan mengingatkan hamba atas kelalaiannya Wahai saudaraku, sesungguhnya di balik penyakit dan musibah akan mengembalikan seorang hamba yang tadinya jauh dari mengingat Allah agar kembali kepada-Nya. Biasanya seseorang yang dalam keadaan sehat wal ‘afiat suka tenggelam dalam perbuatan maksiat dan mengikuti hawa nafsunya, dia sibuk dengan urusan dunia dan melalaikan Rabb-nya. Oleh karena itu, jika Allah mencobanya dengan suatu penyakit atau musibah, dia baru merasakan kelemahan, kehinaan, dan ketidakmampuan di hadapan Rabb-Nya. Dia menjadi ingat atas kelalaiannya selama ini, sehingga ia kembali pada Allah dengan penyesalan dan kepasrahan diri. Allah ta’ala berfirman yang artinya, “Dan sesungguhnya Kami telah mengutus (para rasul) kepada umat-umat sebelummu, kemudian Kami siksa mereka dengan (menimpakan) kesengsaraan dan kemelaratan, supaya mereka memohon (kepada Allah) dengan tunduk merendahkan diri. (QS. al-An’am: 42) yaitu supaya mereka mau tunduk kepada-Ku, memurnikan ibadah kepada-Ku, dan hanya mencintai-Ku, bukan mencintai selain-Ku, dengan cara taat dan pasrah kepada-Ku. (Tafsir Ibnu Jarir) Terdapat hikmah yang banyak di balik berbagai musibah Wahai saudaraku, ketahuilah di balik cobaan berupa penyakit dan berbagai kesulitan lainnya, sesungguhnya di balik itu semua terdapat hikmah yang sangat banyak. Maka perhatikanlah saudaraku nasehat Ibnul Qoyyim rahimahullah berikut ini: “Andaikata kita bisa menggali hikmah Allah yang terkandung dalam ciptaan dan urusan-Nya, maka tidak kurang dari ribuan hikmah (yang dapat kita gali, -ed). Namun akal kita sangatlah terbatas, pengetahuan kita terlalu sedikit dan ilmu semua makhluk akan sia-sia jika dibandingkan dengan ilmu Allah, sebagaimana sinar lampu yang sia-sia di bawah sinar matahari.” (Lihat Do’a dan Wirid, Yazid bin Abdul Qodir Jawas) Ingatlah saudaraku, cobaan dan penyakit merupakan tanda kecintaan Allah kepada hamba-Nya. Rasulullah shallallahu ‘alaihi wa sallam bersabda, “Sesungguhnya Allah ta’ala jika mencintai suatu kaum, maka Dia akan memberi mereka cobaan.” (HR. Tirmidzi, shohih). Ya Allah, anugerahkanlah kepada kami keyakinan dan kesabaran yang akan meringankan segala musibah dunia ini. Amin. *** Penulis: Abu Hasan Putra Sumber: Buletin At-Tauhid

Rahasia di Balik Sakit

Jumat, 15 Februari 2008

Hidup ini tidak lepas dari cobaan dan ujian, bahkan cobaan dan ujian merupakan sunatullah dalam kehidupan. Manusia akan diuji dalam kehidupannya baik dengan perkara yang tidak disukainya atau bisa pula pada perkara yang menyenangkannya. Allah ta’ala berfirman yang artinya, “Tiap-tiap yang berjiwa akan merasakan mati. Kami akan mengujimu dengan keburukan dan kebaikan sebagai cobaan (yang sebenar-benarnya). Dan hanya kepada Kami-lah kamu dikembalikan.” (QS. al-Anbiyaa’: 35). Sahabat Ibnu ‘Abbas -yang diberi keluasan ilmu dalam tafsir al-Qur’an- menafsirkan ayat ini: “Kami akan menguji kalian dengan kesulitan dan kesenangan, kesehatan dan penyakit, kekayaan dan kefakiran, halal dan haram, ketaatan dan kemaksiatan, petunjuk dan kesesatan”. (Tafsir Ibnu Jarir). Dari ayat ini, kita tahu bahwa berbagai macam penyakit juga merupakan bagian dari cobaan Allah yang diberikan kepada hamba-Nya. Namun di balik cobaan ini, terdapat berbagai rahasia/hikmah yang tidak dapat di nalar oleh akal manusia. Sakit menjadi kebaikan bagi seorang muslim jika dia bersabar Rasulullah shallallahu ‘alaihi wa sallam bersabda yang artinya, “Sungguh menakjubkan perkara seorang mukmin, sesungguhnya semua urusannya merupakan kebaikan, dan hal ini tidak terjadi kecuali bagi orang mukmin. Jika dia mendapat kegembiraan, maka dia bersyukur dan itu merupakan kebaikan baginya, dan jika mendapat kesusahan, maka dia bersabar dan ini merupakan kebaikan baginya. (HR. Muslim) Sakit akan menghapuskan dosa Ketahuilah wahai saudaraku, penyakit merupakan sebab pengampunan atas kesalahan-kesalahan yang pernah engkau lakukan dengan hati, pendengaran, penglihatan, lisan dan dengan seluruh anggota tubuhmu. Terkadang penyakit itu juga merupakan hukuman dari dosa yang pernah dilakukan. Sebagaimana firman Allah ta’ala, “Dan apa saja musibah yang menimpamu maka adalah disebabkan oleh perbuatan tanganmu sendiri, dan Allah memaafkan sebagian besar (dari kesalahan-kesalahanmu).” (QS. asy-Syuura: 30). Rasulullah shallallahu ‘alaihi wa sallam bersabda,”Tidaklah menimpa seorang mukmin rasa sakit yang terus menerus, kepayahan, penyakit, dan juga kesedihan, bahkan sampai kesusahan yang menyusahkannya, melainkan akan dihapuskan dengannya dosa-dosanya. (HR. Muslim) Sakit akan Membawa Keselamatan dari Api Neraka Rasulullah shallallahu ‘alaihi wa sallam bersabda yang artinya,” Janganlah kamu mencaci maki penyakit demam, karena sesungguhnya (dengan penyakit itu) Allah akan mengahapuskan dosa-dosa anak Adam sebagaimana tungku api menghilangkan kotoran-kotoran besi. (HR. Muslim). Oleh karena itu, tidak boleh bagi seorang mukmin mencaci maki penyakit yang dideritanya, menggerutu, apalagi sampai berburuk sangka pada Allah dengan musibah sakit yang dideritanya. Bergembiralah wahai saudaraku, sesungguhnya Rasulullah shallallahu ‘alaihi wa sallam bersabda, “Sakit demam itu menjauhkan setiap orang mukmin dari api Neraka.” (HR. Al Bazzar, shohih) Sakit akan mengingatkan hamba atas kelalaiannya Wahai saudaraku, sesungguhnya di balik penyakit dan musibah akan mengembalikan seorang hamba yang tadinya jauh dari mengingat Allah agar kembali kepada-Nya. Biasanya seseorang yang dalam keadaan sehat wal ‘afiat suka tenggelam dalam perbuatan maksiat dan mengikuti hawa nafsunya, dia sibuk dengan urusan dunia dan melalaikan Rabb-nya. Oleh karena itu, jika Allah mencobanya dengan suatu penyakit atau musibah, dia baru merasakan kelemahan, kehinaan, dan ketidakmampuan di hadapan Rabb-Nya. Dia menjadi ingat atas kelalaiannya selama ini, sehingga ia kembali pada Allah dengan penyesalan dan kepasrahan diri. Allah ta’ala berfirman yang artinya, “Dan sesungguhnya Kami telah mengutus (para rasul) kepada umat-umat sebelummu, kemudian Kami siksa mereka dengan (menimpakan) kesengsaraan dan kemelaratan, supaya mereka memohon (kepada Allah) dengan tunduk merendahkan diri. (QS. al-An’am: 42) yaitu supaya mereka mau tunduk kepada-Ku, memurnikan ibadah kepada-Ku, dan hanya mencintai-Ku, bukan mencintai selain-Ku, dengan cara taat dan pasrah kepada-Ku. (Tafsir Ibnu Jarir) Terdapat hikmah yang banyak di balik berbagai musibah Wahai saudaraku, ketahuilah di balik cobaan berupa penyakit dan berbagai kesulitan lainnya, sesungguhnya di balik itu semua terdapat hikmah yang sangat banyak. Maka perhatikanlah saudaraku nasehat Ibnul Qoyyim rahimahullah berikut ini: “Andaikata kita bisa menggali hikmah Allah yang terkandung dalam ciptaan dan urusan-Nya, maka tidak kurang dari ribuan hikmah (yang dapat kita gali, -ed). Namun akal kita sangatlah terbatas, pengetahuan kita terlalu sedikit dan ilmu semua makhluk akan sia-sia jika dibandingkan dengan ilmu Allah, sebagaimana sinar lampu yang sia-sia di bawah sinar matahari.” (Lihat Do’a dan Wirid, Yazid bin Abdul Qodir Jawas) Ingatlah saudaraku, cobaan dan penyakit merupakan tanda kecintaan Allah kepada hamba-Nya. Rasulullah shallallahu ‘alaihi wa sallam bersabda, “Sesungguhnya Allah ta’ala jika mencintai suatu kaum, maka Dia akan memberi mereka cobaan.” (HR. Tirmidzi, shohih). Ya Allah, anugerahkanlah kepada kami keyakinan dan kesabaran yang akan meringankan segala musibah dunia ini. Amin. *** Penulis: Abu Hasan Putra Sumber: Buletin At-Tauhid

Macam-Macam Hati

Sabtu, 29 Desember 2007

Banyak orang menaruh perhatian yang besar terhadap keadaan jasmani mereka. Apakah terlihat bagus, terdapat lecet-lecet, luka-luka atau apakah tubuh sedang terasa kurang fit. Mereka lantas bergegas mencari penanganan dan penyelesaiannya. Tetapi mereka kurang menaruh perhatian yang lebih terhadap hati. Hati merupakan ibarat raja yang memimpin anggota tubuh untuk melakukan suatu amalan, apakah amalannya itu menjadi baik ataukah menjadi buruk. Sebagaimana disebutkan dalam sebuah hadits yang cukup dikenal, bahwasanya sahabat An-Nu’man bin Basyir mengatakan bahwa Rosululloh shollallahu ‘alaihi wa sallam bersabda: “… Ketahuilah bahwasanya di dalam jasad itu ada segumpal daging, apabila ia baik maka baik pulalah seluruh tubuh. Dan apabila ia rusak maka rusak pulalah seluruh tubuh. Ketahuilah (segumpal daging) itu adalah al-qolbu (hati).” (HR. Bukhari dan Muslim). Oleh karena itu hendaklah seorang insan berusaha untuk mengenal tentang hati dan hal-hal yang berkaitan dengan hati. Hati dinamakan al-qolbu karena mempunyai sifat dapat berbolak-balik. Seorang penyair masa lalu melantunkan sebuah bait sya’ir: Tidaklah dinamakan qolbu Melainkan karena berbolak-baliknya Dan dapat memalingkan manusia… Tahap demi tahap Pembagian Hati Para pembaca yang budiman, perlu untuk kita ketahui bersama bahwa hati dapat dikelompokkan menjadi tiga jenis yaitu hati yang sehat, hati yang sakit dan hati yang mati. Hati yang sehat adalah hati yang selamat, yaitu yang membawa seseorang menuju kepada keselamatan di akhirat kelak. Allah Ta’ala berfirman yang artinya: “Adalah hari yang mana harta dan anak-anak tidak lagi bermanfaat, kecuali orang-orang yang datang kepada Allah dengan hati yang selamat.” (Asy-Syuaraa: 88-89) Syaikh Abdurrahman bin Nashir As-Sa’di ketika menafsirkan ayat ini, mengatakan, “Hati yang selamat maknanya adalah selamat dari syirik, kejelekan, keragu-raguan, rasa cinta kepada keburukan, terus-menerus melakukan kebid’ahan dan dosa.” Hati yang mati adalah hati yang tidak mengenal siapakah Rabb (Tuhan) nya. Tidak beribadah kepadaNya yaitu dengan menjalankan perintahnya dan tida pula menghadirkan sesuatu yang dicintai dan diridloiNya. Baginya yang penting adalah menuruti keinginan hawa nafsu. Hawa nafsu telah menjadi pemimpin dan pengendali baginya. Kebodohan adalah sopirnya dan kelalaian adalah kendaraan baginya. Bergaul dengan orang yang mati hatinya ini adalah penyakit, berteman dengannya adalah racun, dan duduk bersama dalam satu majelis dengan mereka adalah bencana. Sedangkan hati yang sakit adalah hati yang hidup tetapi mengidap penyakit. Ia cenderung untuk mengikuti unsur yang lebih kuat. Terkadang ia cenderung kepada ‘kehidupan’, namun terkadang lebih cenderung kepada ‘penyakit’. Padanya terdapat kecintaan, keimanan, keikhlasan, dan tawakal kepada Allah Ta’ala, yang kesemuanya itu merupakan sumber kehidupan. Namun padanya terdapat kecintaan dan ketamakan terhadap syahwat, sifat hasad, sombong dan ujub (berbangga diri), yang merupakan bencana dan sumber kehancuran diri seseorang. Ia berada diantara dua penyeru, yaitu penyeru yang menyeru kepada Allah dan RasulNya, hari akhir dan penyeru yang menyeru kepada kehidupan dunia. Seruan yang disambutnya adalah seruan yang paling dekat dan paling akrab. Oleh karenanya, hendaknya kita berusaha menjadikan hati kita ke dalam jenis hati yang pertama, yang akan membawa diri kita menuju kepada keselamatan dan kebahagiaan. Dan juga berdo’a dengan do’a yang sering dipanjatkan oleh nabi yang mulia Muhammad shollallohu ‘alaihi wa sallam yang diriwayatkan dari jalan sahabat Syahr bin Ausyah radhiyallohu ‘anhu, “Wahai Dzat Yang Maha membolak-balikkan hati, teguhkanlah hatiku di atas agamaMu.” (HR. Tirmidzi, hasan). Dalam riwayat yang lain Rosululloh shollallohu ‘alaihi wa sallam berdo’a, “Wahai Allah Dzat Yang Maha mengarahkan hati, arahkanlah hati kami kepada ketaatan kepadamu.” (HR. Muslim)