2. FISTULA
Abnormal tube like passage from a
normal cavity or tube to a free
surface or to another cavity result
from congenital incomplete closure
of parts or from injuries or
inflammatory processes
4. Entero enteric fistula
Occurs when small intestine joins with -
Another segment of small intestine or
colon
Causes
crohn's disease (commonest)
Colonic diverticulitis
Ca. colon
5. Entero enteric fistula cont.
Ilio-cecal fistulas are commonest
presentation in crohn's disease due to
chronic inflammation of terminal ileum
Jejunum & duodenum involved less
frequently
6. Fistula formation in crohn's disease
Serosal cohesion of healthy bowel to diseased
segment
↓
Gradual internal perforation
↓
Penetration of ulcer through newly formed
common wall
↓
FISTULA
7. symptoms
May symptom less / subtle
abnormalities
Present with - Diarrhea, Abdominal pain,
Weight loss & Fever
These symptoms are not specific
because may be caused by underlying
disease itself
Abdominal tenderness, Abdominal mass
Intestinal obst.
9. Management
Parenteral nutrition
Bowel rest
Pharma. Therapy
6-MP, Cyclosporine, infliximab, Azathioprine
Surgical intervention
Refractory disease
Intolerance to medication
& their side effects
10. Surgical intervention (cont.)
En bloc resection of diseased intestine in continuity
with the fistula tract F/By anastomosis
If inflammation / abscess present
proximal diversion / drainage to allow to
subside for 6 wks. & anastomosis
Resection confined to involved segment to
conserve overall bowel length as excessive
resection can cause
Mal absorption or
Short gut syndrome
11. Entero vesical fistula
Fistula between Ur. Bladder & small / large
bowel
causes
Crohn's disease (> 50%)
Diverticulitis
Ca. colon
Radiation injury
12. Entero vesical fistula (cont.)
These are narrow long & tortuous
Intermittent patency
>80% Pts. Presents with urinary symptoms
Fecaluria
Pneumaturia
Dysuria
Bladder irritability
In some cases Fulminant Sepsis d/t contamination
with intestinal organisms
13. Entero vesical fistula (cont.)
DIAGNOSIS
Ba.Meal or Enema
Oral Charchol
Oral / rectal Indigo cyanine
Cystoscopy
Bullous oedema
Retrograde cystography
C T Scan / M R Imaging (most accurate)
14.
15. Entero vesical fistula (cont.)
SURGICAL MANAGEMENT
In absence of inflammation / obst. / abscess
Resection of diseased intestine + portion of
bladder, primary anastomosis of bowel &
closure of bladder wall
Otherwise
Transaction, coetaneous diversion of prox. &
dist. Segments F/B definitive procedure after 6
wks.
16. Nephro enteric fistula
Fistula between bowel & upper urinary tract
Anatomic proximity is prime determinant for the
affected segment
i.e. Duodenum > Jejunum
Causes
Renal TB. & Other bact. Infections (sec. to
obstructing renal calc.disease eg. stag horn
calc.
Renal trauma (penetrating / blunt / iatrogenic)
Diverticulitis (rare)
17. Nephro enteric fistula (cont .)
SYMPTOMS depends on
Nature of underlying renal disease
Rapidity with which fistula forms
Presence of associated conditions
Diverticulitis
Peri nephric abscess
Pt. Appears chronically ill & debilitated
Presents as chr.UTI (chills &fever)
or
FULMINENT SEPSIS
18. Nephro enteric fistula (cont .)
Flank pain & tenderness on palpation
Fecaluria, Pneumaturia, N & V
Watery purulent diarrhea
Dehydration & Uremia (advanced disease)
Hyperchloremic acidosis
(urine electrolyte re absorption)
19. Nephro enteric fistula (cont .)
DIAGNOSIS
Oral Charchol / indigo carmine
I V Urography
(if involved kidney remains functional)
Retrograde pyelography + cinefluorography
C T Scan (associated Peri nephric abscess)
20.
21. Nephro enteric fistula (cont .)
TREATMENT
Correction of Fluid & elect. Imbalance
Correction of anemia
Broad spectrum AMA.
Nutritional support
Retrograde placement of Ureteric cath. /
Nephrostomy (obst. Uropathy + functional kidney)
22. Nephro enteric fistula (cont .)
Affective kidney has extensive inflammatory
changes (chr.granulomatous disease)
NEPHRECTOMY & Intestinal resection is Rx of
choice
Conservation of involved renal parenchyma
fistula before severe renal impairment
(traumatic fistula)
23. Entero vaginal fistula
Fistula between bowel & vagina
Causes
Post op. complication of Hysterectomy
crohn's disease
chr.granulomatous disease
Malignant tumors
24. Entero vaginal fistula (cont.)
SYMPTOMS
Purulent / feculent vaginal discharge
Intermittent gas discharge from vagina
Associated intra abd. Sepsis
Fever chills & abd. Pain
Signs of hypovolemia with electrolyte imbalance
(profuse discharge)
26. Entero vaginal fistula (cont.)
MANAGEMENT
Local drainage
SUMP drains thru.vagina to control sepsis &
fistula output ↴
Adequate nutritional support + I.V.
alimentation ↴
Spontaneous closure
27. Entero vaginal fistula (cont.)
If fails ↴
resection of cuff of vaginal tissue along with
fistula
with primary resection anastomosis /
delayed
Vaginal defect may left open to allow
external drainage of pelvis
28. Entero uterine fistula,
Entero cervical fistula &
Entero fallopian fistula
Rare varieties
Cause
Pelvic malignancy
Unusual sequel of long standing ectopic
pregnancy
Radiation to cervical stump
Endometriosis
T.B.Salpingitis & L.G.V.
29. Aorto enteric fistula
Commonest fistula between Arterial tree & small
bowel
Causes
Complication of aortic aneurysm
Pancreatic transplantation
Types
Primary
Secondary
30. Aorto enteric fistula (cont.)
PRIMARY AORTO ENTERIC FISTULA
Rupture of plaque of athreosclerotic aortic
aneurysm into intestine
Mycotic / T.B. / traumatic aneurysm rupture into
intestine
III part of Duodenum most often involved
Jejunum / ileum rare
33. Aorto enteric fistula (cont.)
CLINICAL PRESENTATION
Direct communication B/W bowel & arterial lumen
Initially bleeding is intermittent & painless
(herald / sentinel bleeding)
Pt. Presents with Chr. Anaemia +
hemetemesis / malena
or
Massive G.I.Hemorrhage SHOCK & DEATH
34.
35.
36. Aorto enteric fistula (cont.)
Para prosthetic enteric fistula
Bowel communicates with a Para graft
abscess & not directly communicate with
aneurysm
Clinically presents as SEPSIS & Abd. Pain
If untreated ultimately results in a directly
communicating fistula
39. Intestine adjacent to aorta
Aortic pulsations cause trauma to bowel
Fixation of bowel to anastomotic area & / or
leakage of bowel contents
Subsequent infection /
enzymatic digestion of
anastomotic area
↓
Suture line disruption
↓
A.E.F.
Aneurysmal degeneration
of graft + mechanical
erosion of bowel wall
↓
A.E.F.
40. DIAGNOSIS & MANAGEMENT
Herald hemorrhage
G.I.Endoscopy with dist. Duodenum (no biopsy)
C.T.Scan
– Loss of fatty planes b/w aortic graft & duodenum
– False aneurysm
– Para aortic fluid / gas collection
Aortography (active hemorrhage / false aneu.)
Ba. studies
42. Gastro colic & gastro jejuno colic
fistula
Causes
crohn's disease
NSAIDS
Malignancy (gastric adeno Ca, lymphoma)
Peptic ulcer disease
Per cutaneous gastrostomy
Marginal ulceration after G.J.Stomy
43. Gastro colic & gastro jejuno colic fistula
(cont.)
Pt presents with c/o Diarrhea & malnutrition
Short circuiting of food into colon
Bacterial overgrowth in stomach & small
intestine
Diagnosis
Abnormal upper & lower G.I.Endoscopy
Ba. Enema (more suitable)
44. Gastro colic & gastro jejuno colic fistula
(cont.)
MANAGEMENT
Correction of Fluid & elect. Imbalance
Correction of anemia
Broad spectrum AMA.pre & per operative
Nutritional support
En bloc resection of fistula
Gastric, jejunal & Colonic suture lines separated
by omentum
Diversion / by pass procedures
45.
46. Cholecysto enteric fistula
Inflammatory fistula formation due to gall stone
erosion of gall bladder and migration thru its wall
into adjacent II part of duodenum results in
persistent cholecysto duodenal fistula.
May remain asymptomatic.
Symptoms arises due to gall stone ileus with
distal small bowel obst. d/t stones.
47. Choledocho duodenal fistula
Diagnosis
Pneumobilia
ERCP stent may perforate III part of duodenum
if stent migrate outwards from ampulla.
48. Pancreato gastric fistula
Proximal migration of stent into gastric antrum
during Pancreatic duct stenting.
Diagnosis
Fluoroscopic contrast examination.
CT scan with I V contrast.
