background of enteric fistula, causes of enteric fistula, presentation of enteric fistula, investigation of enteric fistula, conservative management and stabilization in patients with enteric fistula and selection of definitive management of enteric fistula

1. ENTEROCUTANEOUS FISTULA
Dr Makanga

2. Patient profile
• Name: CJK
• Age: 26
• Sex: F
• Residence: Baringo
• Occupation: Nursing student
• First contact: 12/05/13
• Last contact: 14/10/13

3. Presentation & Management
• Referral from ?St. Elsewhere
• Abdominal pain, distension, ‘toxic’
• Obvious clinical peritonitis
• T-38, P-118, BP 90/60
• For Emergency lap

4. 13/05/13
• Ex lap – ileal volvulus with gangrene.
Resection + ileostomy fashioned
• Stomal gangrene noted
• Patient sicker post-op

5. 14/05/13
• Re-lap
• Patchy gangrene of ileum – resection x2 plus
ileostomy refashioning
• Again patient gets sicker
• Stomal gangrene

6. 16/05/13
• Re-lap
• More resection of gangrenous ileum and
stomal refashioning
• Abdomen left open
• Central line fixed, NPO, TPN instituted

7. 21/05/13
• Greenish discharge on incision
• Relap – found multiple enterotomies – closed
primarily
• Full ECF care instituted
– Strict NPO, TPN, PRN morphine, K+
– Triple antibotics
– Zinc oxide on skin
– IV fluids to match ileal and fistula output

8. 22/5/13 – 10/6/13
• Patient slowly improves
• Fever controlled, fistula output reduces!
• Skin getting better, abdominal incision closed
• Oral feeds slowly introduced
• Modest weight gain
• Discharged stable
• Closure of ileostomy done 2/9/13
• Now back to nursing school

9. DISCUSSION

11. Classification
• Abnormal communication between gut lumen
and the skin:
– High-output > 500 cc/day (mortality 50%*)
– Moderate-output 200-500 cc/day
– Low-output < 200 cc/day (mortality 20%*)
*Lévy E, Frileux P, Cugnenc PH. High-output external fistulae of the small bowel: management
with continuous enteral nutrition. Br J Surg. 1989 Jul;76(7):676-9

12. Tenets of ECF care
• Identification and resuscitation
• Control of fistula drainage and skin care
• Control of sepsis
• Nutritional support
• Investigation
• Definitive care

13. Identification and resuscitation
• Sign = pus then enteric content from
laparotomy incision
• Volume and electrolyte restoration
• Fluid input-output control (urine output)
• Oxygen, transfusion, albumin as required
• If in septic shock may require inotrope

14. Control of sepsis
• Signs = fever, organ dysfunction, peritonism
• Broad spectrum antibiotics
• Drainage of intraperitoneal abscesses

15. Control of fistula drainage and skin
care
• Sign = acidic or alkaline effluent causes skin to
be excoriated
• Sump suction + VAC system
• Stoma bags
• Adsorbent dressings
• Zinc oxide on sorrounding skin
• Acid suppression and octreotide*?
*Torres AJ, Landa JI, Moren-Azcoita M et al. Somatostatin in the management of gastrointestinal
fistulas: a multicenter trial. Arch Surg 1992;127:97

16. Sump with VAC system

17. Nutritional support
• Usually parenteral – 35-40 kcal/kg/day,
protein 2gm/kg/day
• Enteral - If distal gut is accessible, use it
• Combined feeding
• Monitor response with weekly weight,
prealbumin
• Re-introduce oral feeds judiciously

18. Investigation
• Fistulogram
• CT abdomen
• Water soluble contrast

19. Definitive care –
Which are likely to heal spontaneously?
Factor Favorable Unfavorable
Organ of origin Esophageal, Duodenal stump,
Pancreatic, Biliary, Jejunal,
Colonic
Gastric, Lateral duodenal,
Ligament of Treitz, Ileal
Etiology Postop (anast leak), Appendicitis,
Diverticulitis
Malignancy, IBD
Output Low (<200-500cc/day) High (>500cc/day)
Nutritional status Well nourished Malnourished
Sepsis Absent Present
State of bowel Intestinal continuity, absence of
obstruction
Epithelialization, Distal
obstruction, Abscess,
Discontinuity, Irradiation
Fistula characteristics Tract >2 cm, Defect >1cm Tract <1cm, Defect >1cm
Miscellaneous Original operation at same
institution
Referred from outside
institution

20. Thank you