Ergotamine-induced complex rectovaginal fistula. Report of a case

This report stresses the importance of local complications caused by ergotamine abuse for the treatment of migraine headaches.

We present an unusual case of a complex rectovaginal fistula (RVF) caused by long-term ergotamine suppository abuse.

A 39-year-old female was referred after she had undergone a transverse colostomy for temporary fecal diversion. Evaluation, including proctoscopy, gastrograffin enema, vaginogram, and pelvic computerized tomography revealed a RVF 6 cm proximal to the dentate line with distal rectal stricture. Surgical intervention included take down of the transverse colostomy with reanastomosis, proctectomy with excision of the fistula, creation of a colonic "J-pouch" with a coloanal anastomosis, and construction of a temporary loop ileostomy. The patient had an uneventful recovery, and her ileostomy was closed three months later. Pathologic examination of the surgical specimen failed to reveal any specific etiology of the RVF. However, her ten-year use of up to five ergotamine suppositories per day for migraine treatment is associated with a local ischemic effect. Pathophysiology of this rare cause of RVF and the surgical procedure are discussed.

If evidence of any side effects of ergotamine suppositories is seen, early discontinuation of the drug should be considered to avoid complications such as RVF and/or strictures.