- A fistula is an abnormal connection between hollow viscus and
adjacent organ or skin
- Simple fistula is a direct communication between gut and skin
- Complex fistula is a fistula with associated abscess cavity
- Fistulae, particularly if high output (>500 ml / day) cause:
- Dehydration
- Electrolyte and acid-base imbalance
- Malnutrition
- Sepsis
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 tunnelled 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
Davis K G, Johnson E K. Controversies in the care of
enterocutaneous fistula. Surg Clin North Am 2013; 93:
231-250. |