A presentation that will help clinicians attain the basic diagnostic skills required to effectively manage patients.

1. SURGERY
INTESTINAL FISTULA
DR. CHONGO SHAPI (BSc. HB, MBChB)

2. INTESTINAL FISTULA
Definition
A fistula is an abnormal tract between two
or more epithelial lined surfaces. Tract is
line by granulation or epithelial tissue
It may involve a communication tract from
one body cavity or hollow organ to another
hollow organ or to the skin
Enterocutaneous fistula is an .abnormal
communication between bowel and skin
Classification
There are several ways to classify fistulae
and these are useful in selecting measures
for management and for comparison of
therapeutic approaches.
1. Descriptive includes the sites of origin
and termination: e g jejunocutaneous ,
ileovesical fistulas
2.Anatomical Classification
Modified Sitges-Serra classification
Type 1 fistula are esophageal, gastric, and
duodenal fistulae
Type II fistula Involve small bowel
Type III fistula Involve large bowel and
Type IV fistula where all the above drains
through a large abdominal wall defect.
2. Internal versus external
Internal fistulae include ileocolic or ileoileo
fistulae.
Rarely follow a surgical procedure; usually
result from local perforation of diseased
bowel. An abscess forms that affects an
adjacent structure.
External fistulae include duodenocutaneous
or ileovaginal.
3.Physiologcal classification
Quantifies fistula output over a 24-hour
2. Anastomotic breakdown (85%–
90%) as a result of:
➢ Foreign body close to the
suture line,
➢ Tension on the suture line
➢ Complicated suture
techniques
➢ Distal obstruction
➢ Hematoma, abscess
formation at the anastomotic
site
➢ Sepsis
➢ Tumor
3. Emergent/urgent surgical
procedures involving
➢ Un prepared bowel,
➢ under resuscitation,
➢ malnourishment
➢ or previously radiated tissue
Spontaneous 10%–15%
1. Intestinal diseases such as Crohn’s
disease,malignancy
2. Infectious processes, as in tuberculosis,
diverticulitis,
3. Vascular insufficiency, mesenteric
ischemia.
4. Radiation exposure
Effect of fistula
Loss of enteric contents is attended to by
1.Nutritional deficits due to nutrient loss/
lack of absorptive exposure
2.Loss of fluid, electrolyte and acid base
imbalance
3.Contents contaminate sterile cavities like
peritoneum with sepsis with its attendant
metabolic and immunologic consequences

3. period
-Low volume fistula <200 ml/24-hour
-Moderate volume 200 and 500 ml/24
hours
-High volume >500 ml/24 hours.
4.Etiological
Spontaneous Fistula-arises without prior
surgery.
Iatrogenic-post surgical are the most
common causes. Also post radiation
enteritis.
5.Characteristics of the tract (simple or
complex)
Simple fistulas-Single, short, direct tract,
no abscess associated.
Complex-multiple tracts. Several types
Type 1-abscess or multiple organ
involvement
Type 2 -distal end within the base of a
disrupted wound
6. End fistula, which encompasses the
entire diameter of the bowel, and lateral
fistula, which arises from one side only.
Etiology
Iatrogenic fistulas
Fistulas are either iatrogenic or
spontaneous in development
Iatrogenic….. Surgical misadventure’ or
‘post operative’ is the commonest cause.
Fistulas may develop immediately or years
later in conjunction with other processes
such as diabetes mellitus, pelvic
inflammatory disease, pelvic surgery,
hypertension and atherosclerosis.
Surgical complications that may may cause
fistulas include:
1. Unintentional enterotomy
MANAGEMENT
The goal is to achieve permanent closure of
the fistula in the shortest time and with the
lowest possible risk to the patient. This
achieved either surgically or by
conservative management
These can be categorized into phase Four
phases:
A. Stabilization,
B. Investigations
C. Conservative treatment
D Surgery
Some effects of Sepsis
-Worsens the hypovolemic state
-Increases the metabolic demand worsens
the nutritional state.
-Toxemia and circulatory disturbance can
lead to Multiple Organ Failure Syndrome.
-In presence of sepsis spontaneous closure
cannot occur
Sepsis is mainifested by pyrexia,
leucocytosis, tachycardia and
hypoalbuminemia.
Cachexia may be the only manifestation
Fluid Type/ Origin Of Fistula
-Watery ………Gastric
-Bile ………….Gastric, biliary, duodenum
-Yellow/orange..Small bowel
-Colourless……Pancreas
-Brown fecal…. Large bowel
Presentation.
1. Fever and sepsis.
2. Abdominal pain.
3. Localized abdominal tenderness.
4. External drainage of small bowel
contents.
5.Severely excoriate the skin and
abdominal wall tissues
6.Dehydration and malnutrition-loss of
fluids and nutrients
2.Nutritional assessment and
supplementation
Good nutrition is needed for:
➢ Closure of the fistula
➢ Reduce chances of infection
➢ Appropriate mode of nutrition to
allow gut to rest.
Route of nutritional support either oral,
enteral or parenteral nutrition dependent
➢ upon patient tolerance
➢ ability to ingest sufficient
quantities
➢ the fistula tract location
➢ the bowel mucosa absorptive
capacity
Oral route of nutrition is reasonable for
patients with colonic fistulas.
Patients with esophageal and distal ileum
fistulas could be supported via the enteral

4. A.STABILIZATION
1.Fluid and electrolyte replacement
2.Adequate nutrition
3.Perifistular skin protection
4.Infection control
5.Measures to reduce fistula output
1.Rehydration and electrolyte
replenishment
-Many fistula patients are profoundly
depleted of intravascular and interstitial
volume.
-The gastrointestinal tract secretes 5-9L of
fluids with sodium, potassium, chloride and
bicarbonate daily.
-Loss of these essential electrolytes and
fluid volume threatens the overall
circulatory system.
-Hypovolemia, inadequate tissue perfusion,
renal failure and circulatory collapse can
occur in the presence of a high output
fistula.
-Thus replacement of these fluids with
isotonic saline solution takes first priority.
Monitoring of fluid resuscitation
➢ Central venous pressure
➢ Urine production per hour-at least
30-50ml/hr
➢ Input/output chart -Fluid should be
collected from fistula output,
nasogastric suction, and urine for
measurement of volume output
versus the input of fluid
➢ Skin turgor.
➢ Pulse
-Blood collected for electrolytes and BGA.
Results of these studies assist in correcting
electrolyte deficits and deranged acid-base
balance.
Body weight is recorded daily. Fluid and
electrolyte resuscitation can usually be
accomplished within the first day or two.
-Subsequent maintenance of homeostasis
depends on accurately measuring losses
and replacing them
B.INVESTIGATIONS
Lab investigation
1.FHG-WBC rise with neutrophilia
2.Electrolytes-imbalnces hypokalemia,
route
Ultimately, total parenteral nutrition (TPN)
is the route of choice for those with high
output proximal small bowel fistulas.
Central parenteral hyperalimentation will
allow the intestinal tract to be placed
completely at rest.
3. Measures to protect the Perifistular
skin from excoriation
Fistula drainage fluid must be collected to
avoid excoriation of skin and abdominal
wall tissues and to record volume losses.
Stomahesive appliances eg Ileostomy bag
is placed on the opening to protect skin,
allow for evaluation of spontaneous closure
and monitoring the daily output.
Meticulous skin care is also provided
around the fistula using skin protective
creams eg zinc oxide, Aluminium paste,
karaya powder.
4.Infection control
Local and systemic sepsis treated with
appropriate drainage and antibiotics guided
by appropriate microbiological
investigations
Abscesses should be drained as soon as
they are diagnosed..
Drainage is accomplished, and the fistula
may close as the sump tube is gradually
withdrawn over a period of weeks.
5.Meaures to decrease fistula output
This simplifies management and increases
the rate of spontaneous closure.
The initial measure is the placement of a
nasogastric tube or if long-term use may be
indicated a gastrostomy tube. Sometimes
this can be placed at the time of another
operative procedure.
‘Nothing by mouth’ regimen minimizes
intestinal output as this decreases content
within the intestinal lumen, reduce
intestinal stimulation and
pancreaticobiliary secretions.
Pharmacological methods includes:
-H2 antagonists/PPIs to prevent stress
ulcers and to decrease gastric secretions
-Somatostatin to inhibit stomach, pancreas,
biliary tract and small intestinal secretions

5. hyponatremia
3.LFT-sepsis may cause acute enzyme rise
of liver injury
4.U/C –may show deranged kidney
function due to sepsis
Imaging
Fistulogram
Assess the anatomical features of the fistula
by radiography
Maturation of the fistula track occurs
postoperatively after 7- 10 days. Then
water-soluble iodinated media dye can be
introduced for fistulogram
Fistulogram determines:
1) Origin of the fistula
2) Length of the tract
3) Continuity the bowel
4) Other manifestations such as an
abscess or distal obstruction.
Combination with barium studies can
accurately establish the site of the fistula in
case of difficulty.
Orally administered barium will usually
give the most information, including
information about the size of the leak, the
absence of distal obstruction and the
presence of a tumour, or extent of
inflammatory changes in the intestine itself
Ultrasonography and CT-Scan
US and CT scan of the abdomen useful in
detecting intra abdominal abscesses and US
guided aspiration of the abscess
Hydrogen peroxide enhanced US-
fistulography could be considered
Scintigraphy (Indium 111-WBC
Scintigraphy) is useful in chronic disease
such as Crohns disease …. distinguish
fibrosis or scarring from active disease.
C.CONSERVATIVE MANAGEMENT
This involes the five aspects of
stabilization which are continued.
Once stable ,continuous close monitoring
of
✓ Fluid and electrolyte status
✓ The nutritional status and feeding
✓ Continued protection of skin around
fistula
✓ Control of any infections to
enhance spotenous closure of fistula
tract
9.Hemodynamic instability
10. Complex fistulas.
11.Underlying gut disease- Malignancy
,Irradiated Bowel, Inflammatory Bowel
disease.
12. Flaring sepsis due to abscesses
inadequately drained percutanously.
Sepsis, hemorrhage and evisceration call
for immediate surgical intervention.
Surgical Intervention involves
Exteriorization of the affected bowel ends
followed by definitive surgery after 12
weeks i.e. after the intra abdominal septic
process has been treated remains the
mainstay of surgical treatment.
Muscle Flaps
If previous extensive resection, the use of
muscle flaps may be helpful.
Muscle flaps provide well-vascularized
coverage and help control fistula drainage
when multiple fistulas occur in a large
abdominal wall defect.
Flaps also useful in the presence of
infection because they provide
phagocytically active tissue.
Laparascopy
Advances in instrumentation and
accumulation of experience has allowed
minimally invasive surgery to become an
alternative to laparatomy in selected cases

6. ✓ Measures to decrease output from
fistula with close monitoring of
output from the fistula Control of
fistula by percutaneous intubation
of tract may be done
D. SURGERY
Indications of surgery include the
following
1.Dehiscence of a suture line
2.Presence of distal intestinal obstruction.
3.Presence of foreign body
4.Epitheliazation of the fistulas tract
5.Continuous high output even with
measures to decrease output
6. Extensive disruption of intestinal
continuity>50%
7.A short (< 2 cm) fistula tract
8.Increasing abdominal distension