3. Definition
A GI fistula is an abnormal communication
between the epithelial-lined lumen of the GI tract
and the epithelium of an adjacent viscus or the
skin
15. a. According to the location of the
fistula
Internal fistula
Between two adjacent internal viscus e.g. colovesical
fistula
Tract contained within body
External fistula
Between the gut and the skin e.g. entero-cutanous
fistula
Tract exits through skin
16. b. According to the organ involved
Colonic- Colon
Entero- Small bowel
Vesico- Bladder
Vaginal -Vagina
Cutaneous- Skin
Recto- Rectum
17. c. According to the type of the fistula
Type I GI fistula
Originate from esophageal, gastric and duodenal
sources
Type II GI fistula
Originate from jejunum and ileum
Type III GI fistula
Originate from large bowel
Type IV GI fistula
Originate from large abdominal wall defects greater
than 20cm
18. Morphological Classification
According to the complexity of the fistula
Simple fistula
Simple fistulas are described as short with a direct tract
There is no organ involvement or associated abscess
Have a better prognosis and are likely to close
spontaneously
Complex fistula
Drain to the skin or adjacent bowel through long, often
multiple tracts via an abscess cavity
Have worse prognosis and less likely to close spontaneously
19. Physiological Classification
Physiologic classification quantifies fistula
output over a 24-hour period
Low output fistula
Produces <200 ml/24-hour
Moderate output fistula
Between 200 and 500 ml/24 hours
High output fistula
>500ml/24 hours
20. Pathological Classification
According to the state of the intestine
Primary GI fistula
Arising as a result of a disease in the wall of the gut e.g.
Crohn’s disease
Secondary GI fistula
Arising as a result of injury in the otherwise normal gut
21. Pathophysiology
The gastrointestinal tract secretes five to nine
litres of sodium, potassium, chloride and
bicarbonate daily
The 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
22. Pathophysiology [cont]
The loss of bowel integrity and absorptive
surface area, and the external loss of protein-
rich enteric contents all contribute to the mal-
nutrition and fluid and electrolyte
abnormalities [Malnutrition]
The presence of bowel contents outside the
lumen may lead to localized abscess, soft tissue
infection, generalized peritonitis, or frank
sepsis, depending on whether the bowel leak
communicates with the peritoneal cavity or soft
tissues [Sepsis]
24. History
Depends on whether the fistula is internal or
external
Internal fistula are basically asymptomatic
unless the distal portion of the fistula enters a
structure such as the bladder, rectum or vagina
Reported symptoms such as recurrent diarrhea,
mucus, blood, cystitis, pneumaturia, flatus or
stool from the vagina, perianal /perineal skin
excoriation, pressure and discomfort
25. History [cont]
Excess fluid exudating from a wound or
cutaneously is the usual first indication of an
external fistula
Examination of the fluid will assist in
determining the source [See table next pg]
Skin excoriation rapidly occurs secondary to
the high concentration of digestive enzymes in
the chyme
26. History [cont]
Type of Fistula Loss from Various Fistula Sites
Fluid Type Origin Of Fistula
Watery Gastric
Bile Gastric, biliary,
duodenum
Yellow/orange Small bowel
Colourless Pancreas
Brown fecal Large bowel
Modified from Metcalf C. Enterocutaneous fistulae. Journal of
Wound Care. 1999(3):142.
29. Systemic Examination
Abdominal examination
Leaking feces or fluids from a wound on the
anterior abdominal wall
± Skin excoriation around the wound
Wound or abdominal sepsis
Abdominal tenderness
CVS
RS
32. Radiological studies
Fistulogram
To determine the anatomy and characteristics of the fistula
Abdominal US
To identify any abdominal collections, abscess, masses etc
US-guided abscess drainage
CT scan of the abdomen
To identify any abdominal collections, abscess, masses etc
US-guided abscess drainage
34. Management
The approach to fistula management have been
organized into four phases:
Stabilization
Investigations
Conservative treatment
Definitive Surgery
35. Phase I. Stabilization
Resuscitation
Control of sepsis
Nutritional support
Control of fistula drainage
Local skin care / protection
36. i. Resuscitation
Restoration of circulating volume is the first goal
Crystalloid resuscitation is required to correct for
losses into the bowel wall and third spaces
Transfusion of red blood cells will improve
oxygen-carrying capacity
Infusion of albumin will help restore plasma
oncotic pressure
37. ii. Control of sepsis
Failure to control sepsis leads to:-
Multi-organ failure
Ineffectiveness of any nutritional support owing to
catabolism
Failure of fistula healing
Death
The control sepsis can be achieved by:-
Open surgical or CT scan/ US drainage
Antibiotics
38. iii. Nutritional support
Nutrition is essential for maintenance while awaiting
spontaneous fistula closure or as the preliminary to
surgical closure of the fistula
May be enteral nutrition or parenteral nutrition
Enteral nutrition is > parenteral nutrition when most of
the gut is available for digestion and absorption of food
Enteral nutrition promotes gut adaptation and maintain
GI function
Parenteral nutrition is preferred when there is little gut
for digestion and absorption
39. iv. Control of fistula drainage
Nil per oral minimizes intestinal output by decreasing
content within the intestinal lumen, intestinal
stimulation and pancreaticobiliary secretions, which
ordinarily would activate the fistula
Acid suppression with H2-receptor antagonists or
proton-pump inhibitors may decrease the volume and
acidity of gastric secretion
Somatostatin and its synthetic analogue Octreotide,
inhibits the release of practically all known gut
hormones and decreases splanchnic and portal
flow,thereby decreasing the fistula output
40. v. Local skin care / protection
Protect skin from effluent
Wafers eg Duoderm, Coloplast
Pastes eg Karaya, Softpaste
Lotions eg Cavilon,Dansac- use as spray or spread
Powders egOrahesive- removes fluid from moist skin
Stoma bags
Treatment of primary skin pathology
Eczemas eg topical sucralfate
Psoriasis eg betamethasone lotion
Pyoderma gangrenosum eg tacrolimus
42. Phase III. Conservative treatment
Wait for spontaneous closure
Spontaneous closure of a colonic fistula can take
30–40 days; an ileal fistula 40–60 days
90% of enteric fistulas that do close will do so
within 50 days
43. Conservative treatment [cont]
A fistula will not close spontaneously in the presence
of:-
Discontinuity of bowel ends
Distal obstruction
Chronic abscess
Mucocutanoeous continuity of the fistula with skin
Demaged or diseased residual intestine
Malnutrition
Foreign bodies
Malignancy involving the GIT
44. Conservative treatment [cont]
Adequate nutrition
Eliminate sepsis
Psychological support
Care of the perifistular skin
45. Phase IV: Definitive Surgical care
Indications:-
Failed conservative treatment
Discontinuity of bowel ends
Distal obstruction
Chronic abscess
Mucocutanoeous continuity of the fistula with skin
Demaged or diseased residual intestine
Malnutrition
Foreign bodies
Malignancy involving
46. Definitive Surgical care [cont]
The timing of closure varies between 10 weeks to 13
months
Premature attempts at operative closure with inflamed,
erythematous or necrotic tissue increases the risk of
peritoneal contamination, the formation of dense
adhesions and recurrent fistula formation
Delaying laparotomy reduces the risk of peritonitis,
minimizes blood loss between anatomical planes at the
time of dissection and improves wound closure and
healing
47. Definitive Surgical care [cont]
The approach will be either resection of the
fistula or diversion of the fecal stream proximal
to the fistula, creating an ostomy or end-to-
end/side-to-side anastomosis.
49. Prognosis
Factor Good prognosis Poor prognosis
Organ of origin Esophageal
Duodenal stump
Pancreatic, biliary,
colonic
Gastric, lateral
duodenum, ligament
of tretz, ileal
Etiology Post-operative
(anastomotic leak),
appendicitis,
diverticulitis
Inflammatory bowel
diseases,
malignancy,radiation
50. Prognostic factors
Fistula
characteristics
Low output, simple
fistula, defect <1cm
High output,
complex fistula,
defect>1cm
Nutrition
status
Well nourished Malnourished
Sepsis Absence Presence
Miscellaneous Operation performed
at the same institution
Referred from
outside institution
51. Conclusion
Medical and nursing care demand a complementary,
interdisciplinary approach if successful closure of a GI
fistula is to be achieved
The patient and family are challenged by physical and
psychological stressors, which often result in weeks and
even months of hospitalization
As health-care practitioners we must remember to treat
the patient as a whole person and not just ‘as a hole.’
The fistula should not become the only focus of care,
but rather an element of the overall treatment plan.
52. Conclusion [cont]
Early diagnosis of the fistula and resuscitation
of the patient, the control of sepsis, and the
provision of nutritional support may limit the
morbidity and mortality associated with this
complication