BY DR KACHE S A

SURGERY DEPT ABUTH, SHIKA ZARIA

MODERATOR ; DR UKWENYA
 DEFINITION

OVERVIEW OF INTESTINAL FISTULAE

CLASSIFICATION OF ENTEROCUTANEOUS FISTULA
AETIOLOGY

PATHOPHYSIOLOGY

MANAGEMENT PROTOCOL
PREVENTION

CONCLUSION
 Enterocutaneous fistula is an abnormal
communication between a intestine & the
skin. It is also called external intestinal fistula

The communication(track) is usually formed

by granulation tissue but in some cases may
be lined by epithelium
 INTERNAL-communication between 2 or more
hollow viscera, without external communication
EXTERNAL(ENTEROCUTANEOUS)-when a hollow
viscus discharges to body surface
MIXED-when both components are present
SIMPLE-single direct track
COMPLICATED/-multiple tracks or an assoc
abscess cavity
LATERAL-arising from side of a hollow viscus
END FISTULA-arising from whole circumference of
the involved bowel & there is no further continuity
of the gut
 VOLUME OF OUTPUT-

Highoutput- >500ml/24hrs
Moderate Output- 200-500ml/24hrs

Lowoutput- <200ml/24hrs, with exception of

pancreatic & hepatobilliary fistulae

ANATOMIC SITE-Proximal & distal

XTIC OF TRACK- Simple or Complicated

CIRCUMFERENCE- End fistula or lateral fistula

 Proposed by Siteges-Sera et al & modified by Schein et
al as follows

TYPE MORTALITY RATE

I. Abdominal oesophagus + gastroduodenal fistulae

17%

II. Small bowel fistulae 33%

III. Large bowel fistulae 20%

IV. Fistula at any site with assoc large abd. Wall defect
60%
 SURGERY-(commonest cause) .usually due to
unrecognised injury to bowel as a result of careless
dissection or due to breakdown of anastomosis

TRAUMA- Blunt or Penetrating

SPONTANEOUS EXTENSION of intraabdominal dx

thru the abd wall e.g

I. Sloughing of a strangulated hernia

II. Pointing of an empyema of the gallbladder

III. Duodenal ulcers eroding thru abd. wall

 INFLAMATORY CONDITIONS such as TB,
Anastomotic ulcer & diverticular dx, chrons
dx

RADIATION ENTERITIS- presents several years

after initial exposure

CONGENITAL- e.g patent vitello-intestinal

duct(umbilical fistula)
 Loss of GI Content
Hypovolaemia, Acid-base and electro-
lyte abnormalities, Malnutrition.

Sepsis
Intra-abdominal sepsis
Wound infection

Skin problems.

Anaemia
 Portion of gut below the fistula is by-passed
resulting in malabsorption of essential nutrients

Fistula + complications + catabolic effects of

sepsis = increased energy expenditure

Body stores of glycogen & fat are progressively

depleted & proteins mainly from muscles

Vit & trace element def. also occur

Resistance to infection & impaired wound healing

 If fistula track is not effectively walled off from
surrounding structures , there is escape of enteric
content into normally sterile areas such as
peritoneal or pleural cavities

Fistula is unlikely to close in presence of sepsis

Assoc. toxaemia & circulatory disturbances may

result in multiple organ failure
 High fluid loss:

Large fistula

High fistula

Distal obstruction
 Advances in electrolyte replacement & nutritional
support measures have allowed surgeons to
maintain pts in a good condition until the fistula
closes spontaneously or the pt becomes fit for a
definitive surgical correction

Attempts at early surgical closure, in an effort to

avoid the problems of fluid & electrolyte
imbalance, malnutrition & sepsis, were assoc. with
very high mortality rates(Monod Broca 1977)
 Sheldon et al(1971) suggested a four phase
approach that could successfully put mgt priorities
in order

PHASE

I. Resuscitation & stoma care

II. Institution of nutritional treatment

III. Investigations & continuing nutritional Rx

IV. Definitive treatment plan

RESUSCITATION- follow ABC
-correct hypovolaemia, restore fluid & electrolyte
balance using plasma substitute, blood transfusion

-maintain on daily req. + est. loss via fistula

PROTECTION OF SKIN & COLLECTION OF FISTULA

EFFLUENT- main aim of stoma mgt is the
application of effective skin protectives & a
disposable drainage bag which will collect effluent
& allow accurate measurement
 Irving & Beadle(1982) classified skin problems
assoc. with ECF into four categories

I. A single orifice passing thru an intact abd. Wall or

otherwise healed scar around which the skin is
flat & in reasonably good condition

II. Single or multiple orifices passing thru the abd

wall close to bony prominences, surg. Scars, other
stomas, the umbilicus

III. Fistula thru small dehiscence of main wound

4. Fistula thru a large dehiscence or at bottom of
gaping wounds

Stoma mgt cat. 1-silicon barrier preparation

-apply adhesive drainable bags

Extra skin protection(adhesive wafers)-in high

output fistula

Stoma mgt cat 2-severely excoriated skin,

impossible for any appliance to adhere

-Nurse pt face down on a split bed or Stryker frame

for up to 48hrs
Stoma mgt cat 2 cont- use large sheets of adhesive
wafer(20x20)

-cut to fit various holes in the abd

-protective paste can be used to seal edges

-Apply large bag(sometimes 2 or 3 small bags)

-if abd scarred by previous surg, resulting grooves &

gullies shd be filled

Stoma mgt cat 3- use adhesive wafers

-large sized bags
Stoma mgt cat 4

-Initially low pressure sump suction drainage to

remove effluent

-This is continued until the wound shrinks to a

size that can be managed by the techniques
described above
 Aim is to provide adequate & sustained
nutritional Rx in order to maintain the pt, until
the fistula closes spontaneously or until the pt is
fit for surgery.

High output or proximal fistula- commence

parenteral nutrition within 48hrs.once phase I
procedures have been completed

If subsequent invx reveal >100cm of

functioning small bowel, proximal or distal to
the fistula, it may be possible to phase in enteral
regimens
 In pts with low output or distal fistula, enteral
feeding can be commenced from the beginning

Parenteral nutrition-via central feeding lines

Enteral nutrition-orally

-NG tube

-Gastrostomy, Jejunostomy
 Nitrogen requirement= Daily urinary nitrogen
excretion + 3-4g
Septic pts=25-30g(10-15g)
Energy Req = 4000-5000kcal/day(rarely exceeds
2000-3000kcal/day)

ENTERAL PREPS- Elemental diet of AA,

Oligopeptides, Triglycerides, Simple sugars
preferably in liquid form
Said to be totally absorbed from 150-250cm of
small bowel
E.g conplan, casilla, astymin
 Once nutritional Rx has been established the pt is
investigated fully to answer the following questions

1. What is the origin of the fistula & the anatomy of

its track

2. What is the condition of the bowel at the site of

the fistula? discontinuity or active disease

3. Is there obstruction distal to the fistula?

4. How much normal bowel is available?

5. Is there an assoc. abscess cavity?

CLINICAL EVALUATION
Hx of surgery
Hx of discharging wound from surgical scar or any
other part of the body
Hx of underlying dx
Hx of fever, abd. Pain
Hx of bowel habit; is pt passing stool or not

O/E
Fever, tarchycardia, abd. Tenderness, guarding,
rigidity
Signs of Dehydration & Malnutrition
Discharging wound
FISTULOGRAPHY- valuable for narrow well defined
fistula opening, doubtful value for high output
fistula in depths of gaping wounds
-outline track & abscess cavity

BARIUM CONTRAST STUDIES-outline track, abscess

cavity, demonstrate length of remaining bowel

ULRASOUND SCANNING- abscess cavity

CT SCAN- abscess cavity, Percut. Drainage

ENDOSCOPY- useful in revealing underlying dx
ROUTINE INVX- Fbc, U&E
 If pt is improving & flow charts indicate a falling
fistula effluent & a rising plasma albumin & body
wt- it is worth persisting with non-surgical Rx
without time limit(Alexander Williams & Irving
1982)

However, if peritonitis or abscess cavity is present-

urgent operative Rx shd be instituted

In the absence of spontaneous closure within 4-

6wks of nutritional support- surgical closure shd
be undertaken
FACTORS RESULTING IN FAILURE OF SPONTANEOUS
CLOSURE
Complicated fistula with abscess cavity

Distal obstruction

Total discontinuity of bowel ends

Mucocut. Continuity(short track <2cm) or

epithelialized track

Radiation enteritis

Presence of active dx at site of fistula

 TREATMENT OF COMPLICATIONS

Infection- antibiotics indicated in resp, uti,

septicaemia, spreading cellulitis, I & D for abscess

Haemorrhage-bleeding may arise from

I. Erosion of a bld vessel by an abscess cavity

II. Stress ulceration due to assoc severe sepsis

From underlying dx e.g pud, neoplasm

III.
RX-H2 antagonist
-pack abscess cavity following drainage

-selective embolization

Venous thromboembolism

-Anticoagulants

PHARMACOLOGIC TREATMENT
H2 Antagonist gastroduodonal fistulae

Somatostatin Analogues (Octreotide) small bowel

fistulae
 Those designed to improve pts condition
I&D for abscesses
Insertion of central lines
Creation of feeding enterostomies

Those designed to close the fistula

Usually a staged procedure
Incision shd be extensive, commencing from
virgin area of abdomen
In septic pts- initial resection, anastomosis at a
later date
 In non septic pts- resection + prim end to
end anastomosis done
 Identification of high risk individuals.

Meticulous surgical technique.

Proper use of peri-operative antibiotics.

Thorough preoperative bowel preparation.

 Most uncomplicated ECF will close
spontaneously when properly managed

Surgery is usually not an immediate priority

except to deal with complications

When surgery is required, fistula resection &

anastomosis or by-pass procedures are the
preferred surgical procedures