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Enterocutaneous fistulae

  • A fistula is an abnormal connection between hollow viscus and adjacent organ or skin
  • Simple fistula = direct communication between gut and skin
  • Complex fistula = fistula with associated abscess cavity
  • Fistulae, particularly if high output (>500 ml / day) cause:
    • Dehydration
    • Electrolyte and acid-base imbalance
    • Malnutrition
    • Sepsis

Small bowel fistula

Aetiology

  • Anastomotic leaks
  • Trauma - often iatrogenic post surgery
  • Inflammatory bowel disease
  • Malignancy
  • Radiotherapy

Imaging

  • Important to determine anatomy of fistula
  • Fistulography will define tract
  • Small bowel or barium enema will define state of intestine or distal obstruction
  • US and CT will define abscess cavities

Management

  • Usually conservative management - at least initially - consisting of

Skin protection

  • Upper GI contents are very corrosive

Correction of fluid and electrolyte loss

  • Require careful fluid balance
  • Restoration of blood volume

Correction of acid-base imbalance

  • H2 Antagonist, proton pump inhibitor to reduce gastric secretions
  • Somatostatin analogues (e.g. Octreotide) to reduce GI and pancreatic secretions

Nutritional support

  • Restrict oral intake and possibly an nasogastric tube
  • Malnutrition corrected with either parenteral or enteral nutrition
  • Total parenteral nutrition given via Dacron-cuffed tunneled feeding line
  • Radiological screening to ensure tube in correct site
  • Enteral nutrition can be given distal to fistula

Control of sepsis

  • Abscess cavities should be drained
  • Antibiotics to be avoided

Enterocutaneous fistulas will not close if:

  • There is total discontinuity of bowel ends
  • There is distal obstruction
  • Chronic abscess cavity exists around the site of the leak
  • Mucocutaneous continuity has occurred

Fistulas are less likely to close if:

  • They arise from disease intestine (e.g. Crohn's Disease)
  • They are end fistulae
  • The patient is malnourished
  • They are internal fistulas
  • 60% will close in one month once sepsis has been controlled with conservative treatment
  • Mortality associated with fistula is still at least 10%
  • Surgery should be considered if fistula does not close by 30-40 days

Bibliography

Blowers A L  Irving M.  Enterocutaneous fistulas.  Surgery 1992; 10.2: 27 - 31

Dubrick S J,  Maharaj A R,  McKelvey A A.  Artificial nutritional support in patients with gastrointestinal fistulas.  World J Surg 1999;  23:  570-576.

Mcintyre P B.  Management of enterocutaneous fistulas: a review of 132 cases.  Br J Surg  1984; 71: 293 -296.

 

 
 

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