INTESTINAL FISTULAE

Amr Mohsen, MD, FRCS(Ed)

Definition
Abnormal communication between intestinal lumen and that of another hollow organ or the skin

Nomenclature
According to the sites they join

Types
Aetiology Internal or external Part of intestine that is affected Output
Higher fistulae are more serious

Greater fluid & electrolyte loss The drainage has greater digestive capacity Important bowel segment is not available for absorption

Aetiology
Intentionally induced
e.g., enteroanastomosis, biliary-enteric anastomosis, colostomy, ileostomy

Postoperative
Pathologic
Congenital Traumatic
Malignancy Anastomotic leak Injury of bowel or its blood supply Laceration of bowel by mesh Laceration of bowel by retention sutures Laceration of bowel by missed sponges

Inflammatory

Radiation damage

30-40% of external fistulae heal spontaneously in 6 weeks

Causes of a persistent fistula

1. Distal obstruction

2. Special pathology Chrohns, TB, malignancy, radiation

3. Local sepsis, FB 4. Mucosa to skin or mucosa (epithelialization of track) 5. High-output fistulae tend not to heal

Complications
1. Malnutrition. External loss, malabsorption, sepsis 2. Fluid & elctrolyte imbalance 3. Sepsis. Localized peritonitis, wound sepsis, distant
infection

4. Skin excoriation 5. Haemorrhage. Rare but fatal

Ileal fluid content mEq/ L

Na 100 K 5 Cl 65 HCO3 30

Evaluation of entero-cutaneous fistula

1. History 2. Examination. Site, character of discharge, VOLUME 3. Imaging
4. Lab tests. CBC, culture & sensitivity, electrolytes, albumin

D.D.
Small leak vs localized peritonitis with feculent pus

Imaging Aim
1. Fistula anatomy 2. Look for an abscess

Imaging Methods
1. Fistulography

2. Ba enema
3. Ba meal-follow through 4. U/S or CT

3. Distal obstruction
4. Special pathology

Treatment
1. Correct water & electrolyte deficit

2. Control sepsis
3. Control external drainage 4. Correct malnutrition 5. Spontaneous closure 6. Operative repair

Sepsis requires
1. Drainage

Control ext. drainage

Catheters & collection bags NPO reduces secretions Somatostatin analog

2. Drainage

3. Drainage
4. Antibiotics

Feeding
Parenteral in most cases Oral for distal low-output fistulae (elemental diet)

Operative treatment of external fistula

1. Whom to operate upon? 2. How to prepare for surgery? 3. When to interfere? 4. What to do at operation?

Operative treatment of external fistula

Indications
1. Failure of healing in 6 weeks 2. Distal obstruction 3. Special pathology 4. Foreign body 5. Pouting mucosa attached to skin

Operative treatment of external fistulae

Principles
1. Elective in non-septic well-nourished patients 2. Identification of fistula

3. Resection of the fistula and damaged bowel segment

4. Restore bowel continuity 5. Difficult cases 2-stage surgery 1st stage exclusion 2nd stage excision of fistula & unhealthy bowel

Results
30-40% of external enteric fistulae heal spontaneously

Mortality for high-output fistulae

>50% in 1960s
Dropped to 20%

Major causes are Sepsis & RF

Professor M. Keighley Birmingham University

French Hospital Tuesday 10.30 am

The rationale of screening for colorectal cancer