High output gastrointestinal fistula management

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High output gastrointestinal fistula management

  1. 1. High output gastrointestinal fistula management B86401103 Ri 烏惟新
  2. 2. Definition <ul><li>Fistula: </li></ul><ul><ul><li>Abnormal pathological communication between two epithelialized surfaces. </li></ul></ul>
  3. 3. Categorization <ul><li>Anatomical </li></ul><ul><li>Physiological </li></ul><ul><li>Etiological </li></ul>
  4. 4. Anatomy <ul><li>External </li></ul><ul><li>Internal </li></ul><ul><li>Proximal </li></ul><ul><li>Distal </li></ul><ul><li>Simple </li></ul><ul><li>Complicated </li></ul>
  5. 5. Physiology <ul><li>High-output fistula </li></ul><ul><ul><li>Pancreatic fistulae </li></ul></ul><ul><ul><ul><li>>200 ml/24 hours </li></ul></ul></ul><ul><ul><li>Intestinal fistulae </li></ul></ul><ul><ul><ul><li>>500 ml/24 hours </li></ul></ul></ul><ul><li>Low-output fistula </li></ul><ul><ul><li>Pancreatic fistulae </li></ul></ul><ul><ul><ul><li><200 ml/24 hours </li></ul></ul></ul><ul><ul><li>Intestinal fistulae </li></ul></ul><ul><ul><ul><li><500 ml/24 hours </li></ul></ul></ul>
  6. 6. Etiology <ul><li>Abdominal surgical procedure </li></ul><ul><ul><li>Leading cause, 67-85% </li></ul></ul><ul><li>Inflammatory bowel disease </li></ul><ul><li>Diverticular disease </li></ul><ul><li>Malignancy </li></ul><ul><li>Radiation enteritis </li></ul><ul><li>Trauma </li></ul><ul><li>Congenital </li></ul><ul><li>Other causes </li></ul>
  7. 7. Abdominal surgical procedures <ul><li>Predisposing factor </li></ul><ul><ul><li>Cancer </li></ul></ul><ul><ul><li>Inflammatory bowel disease </li></ul></ul><ul><ul><li>Lysis of adhesions </li></ul></ul><ul><ul><li>Peptic ulcer </li></ul></ul><ul><ul><li>Pancreatitis </li></ul></ul><ul><ul><li>Emergency </li></ul></ul><ul><ul><li>Technical failure </li></ul></ul>
  8. 8. Complications <ul><li>Loss of GI contents </li></ul><ul><ul><li>Hypovolemia </li></ul></ul><ul><ul><li>Acid-base and electrolyte abnormalities </li></ul></ul><ul><li>Malnutrition </li></ul><ul><ul><li>Lack of food intake, loss of protein in fistula discharge, hypercatabolism associated with sepsis </li></ul></ul><ul><li>Sepsis </li></ul><ul><li>Skin excoraiation </li></ul><ul><li>Hemorrhage </li></ul><ul><li>Psychological effect </li></ul>
  9. 9. High output fistula <ul><li>Fistula output </li></ul><ul><ul><li>A predictor of morbidity and mortality </li></ul></ul><ul><ul><li>Not an independent indicator of spontaneous closure </li></ul></ul><ul><li>Fistula mortality rates have decreased over the past few decades from as high as 40–65% to 5.3–21.3% </li></ul><ul><li>High output fistulae continue to have a mortality rate of approximately 35% . </li></ul>
  10. 10. Clinical/physical signs <ul><li>Slow or unusual course of post-operative recovery </li></ul><ul><li>Abdominal pain or tenderness </li></ul><ul><li>Fever, and leukocytosis </li></ul><ul><li>Skin: </li></ul><ul><ul><li>Cellulitic appearance </li></ul></ul><ul><ul><li>Excessive drainage </li></ul></ul><ul><ul><li>Abscess formation </li></ul></ul>
  11. 11. Evaluation <ul><li>History </li></ul><ul><li>Physical examination </li></ul><ul><li>Radiographic studies </li></ul><ul><li>Laboratory studies </li></ul>
  12. 12. Image study <ul><li>Contrast radiography </li></ul><ul><ul><li>fistulography, oral contrast , contrast enema, pyelography, cystography </li></ul></ul><ul><li>Endoscopy </li></ul><ul><li>Abdominopelvic CT scan, MRI, ultrasound </li></ul><ul><li>X-ray </li></ul>
  13. 13. Management <ul><li>Conservative </li></ul><ul><ul><li>Fluid resuscitation </li></ul></ul><ul><ul><li>Correct acid-base and electrolyte abnormalities </li></ul></ul><ul><ul><li>Complete bowel rest </li></ul></ul><ul><ul><li>Nutritional support </li></ul></ul><ul><ul><li>Infection control </li></ul></ul><ul><ul><li>Fistula drainage </li></ul></ul><ul><ul><li>Skin protection </li></ul></ul><ul><li>Surgery </li></ul>
  14. 14. Fluid resuscitation <ul><li>Correct hypovolemia </li></ul><ul><li>Accurate measurement of ongoing fluid losses </li></ul><ul><li>Intravenous fluid administration </li></ul><ul><ul><li>Iso-osmotic and high in potassium </li></ul></ul><ul><ul><li>Replaced with a balanced salt solution that contains added potassium </li></ul></ul><ul><ul><li>Sample of fistula fluid </li></ul></ul>
  15. 15. Correct acid-base and electrolyte abnormalities <ul><li>Site of the fistula </li></ul><ul><li>Quantity of fluid loss </li></ul><ul><ul><li>High-output gastric fistulas </li></ul></ul><ul><ul><ul><li>Hydrochloric acid </li></ul></ul></ul><ul><ul><li>Biliary and pancreatic fistula </li></ul></ul><ul><ul><ul><li>Hypertonic </li></ul></ul></ul><ul><ul><ul><li>Large bicarbonate and sodium losses </li></ul></ul></ul>
  16. 16. Complete bowel rest <ul><li>Reduce fistula drainage </li></ul><ul><ul><li>Solid food stimulates secretion of digestive juices and therefore increases fistula output, exacerbating poor nutritional status and limiting healing </li></ul></ul><ul><li>Simplify the evaluation </li></ul>
  17. 17. Nutritional support <ul><li>Early, aggressive parenteral nutritional therapy has dramatically decreased mortality from fistulas from 58% to 16% (am J surg 108:157, 1964). </li></ul><ul><li>Therapeutic role </li></ul><ul><ul><li>Decrease in fistula output </li></ul></ul><ul><ul><li>Modify the composition of gastrointestinal pancreatic secretions </li></ul></ul>
  18. 18. Role of TPN <ul><li>Conservative treatment with TPN </li></ul><ul><ul><li>Reduce the maximal secretory capacity of the gastrointestinal tract by 30–50% </li></ul></ul><ul><ul><li>Not suppress basal or cephalic secretions </li></ul></ul><ul><ul><li>Long term administration the presence of lipids and amino acids can stimulate GI secretions </li></ul></ul><ul><li>TPN complications </li></ul><ul><ul><li>Bacterial translocation, superinfection of central venous access, and metabolic disorders as a result of fistula losses </li></ul></ul>
  19. 19. Nutritional support <ul><li>Enteral feeding </li></ul><ul><ul><li>Primary method of choice </li></ul></ul><ul><ul><li>Esophagus, distal ileum, and colon </li></ul></ul><ul><ul><li>Given below proximal fistula if accessible </li></ul></ul><ul><li>Parenteral nutrition </li></ul><ul><ul><li>Intolerance to enteral nutrition </li></ul></ul><ul><ul><li>Gastroduodenal, pancreatic, or jejuno-ileal fistulae </li></ul></ul><ul><ul><li>Proximal fistulas if distal enteral access is not possible </li></ul></ul><ul><li>Reinfusion into the distal bowel </li></ul>
  20. 20. Infection control <ul><li>Intraabdominal abscess </li></ul><ul><li>Intravenous antibiotics </li></ul><ul><li>Infected wounds </li></ul>
  21. 21. Fistula drainage <ul><li>Wound management </li></ul><ul><ul><li>Dressings </li></ul></ul><ul><ul><li>Intubation </li></ul></ul><ul><ul><li>Suction or sump drainage system </li></ul></ul><ul><li>Pharmacotherapy </li></ul><ul><ul><li>Octreotide </li></ul></ul><ul><ul><li>H2-receptor antagonists </li></ul></ul>
  22. 22. Skin protection <ul><li>Barrier device </li></ul><ul><li>Powder </li></ul><ul><li>Examined and cleansed frequently </li></ul>
  23. 23. Surgical treatment <ul><li>Fistulas fail to heal with nonoperative measures </li></ul><ul><li>Sepsis cannot be controlled </li></ul>
  24. 24. Spontaneous closure unlikely.. <ul><li>FRIEND </li></ul><ul><ul><li>Foreign body </li></ul></ul><ul><ul><li>Radiation injury </li></ul></ul><ul><ul><li>Inflammatory bowel disease </li></ul></ul><ul><ul><li>Epithelialization of fistular tract </li></ul></ul><ul><ul><li>Neoplasia </li></ul></ul><ul><ul><li>Distal obstruction </li></ul></ul>
  25. 25. Fistula site: • Oropharyngeal • Esophageal • Duodenal stump • Pancreatobiliary • Jejunal Fistula site: • Gastric • Lateral duodenal • Ligament of Treitz • Ileal   Enteral defect <1 cm Enteral defect >1 cm Fistula tract >2 cm — non-epithelialised Fistula tract <2 cm — epithelialisation Free distal flow Distal obstruction Adjacent bowel healthy Adjacent bowel diseased No associated abscess Large adjacent abscess End fistula Lateral fistula Favourable Unfavourable
  26. 26. High output fistula <ul><li>High morbidity and mortality </li></ul><ul><li>Strategy to reduce both output volume and the content of corrosive enzymes in the exudate would be likely to decrease the healing time, greatly improving prognosis </li></ul>
  27. 27. Somatostatin-14 in combination with TPN <ul><li>Accelerated spontaneous closure of postoperative gastrointestinal fistulae, significantly reducing the required period of TPN treatment (time to healing 13.9±1.84 days somatostatin-14+tpn v 20.4±2.98 days TPN alone; N=20, respectively; Ph0.05) with a consequent reduction in morbidity (35% somatostatin-14+tpn v 68.85% TPN alone; Ph0.05). </li></ul><ul><li>Inhibit both basal and stimulated digestive secretion, as well as reducing fluid loss, electrolyte imbalance, and malnutrition, leading to potential reductions in fistula output and time to closure. </li></ul>
  28. 28. Mechanisms of octreotide <ul><li>Inhibits the release of gastrin, cholecystokinin, secretin, motilin, and other GI hormones. </li></ul><ul><ul><li>Decreases secretion of bicarbonate, water, and pancreatic enzymes into the intestine, subsequently decreasing intestinal volume. </li></ul></ul><ul><li>Relaxes intestinal smooth muscle, thereby allowing for a greater intestinal capacity. </li></ul><ul><li>Increases intestinal water and electrolyte absorption </li></ul>
  29. 29. Reasons for pharmacotherapy <ul><li>Rapidly reduce fistula output </li></ul><ul><ul><li>Improvement in nutritional and electrolyte status </li></ul></ul><ul><ul><li>Reduction of the concentration of caustic enzymes in the discharge will convey beneficial effects on both wound healing and nutritional losses </li></ul></ul><ul><li>Significantly shorten healing time </li></ul><ul><ul><li>Shortening hospitalisation </li></ul></ul><ul><ul><li>Improvements in quality of life </li></ul></ul><ul><ul><li>Reductions in overall treatment costs </li></ul></ul><ul><li>However, lacking data from large scale, double blind, randomised, controlled studies </li></ul>
  30. 30. Guideline : Somatostatin use
  31. 31. Guideline : GI fistula management
  32. 32. Summary: high output GI fistula management <ul><li>Early detection </li></ul><ul><li>Stabilize the patient </li></ul><ul><ul><li>Aggressive fluid resuscitation </li></ul></ul><ul><ul><li>Electrolyte and acid-base balance </li></ul></ul><ul><ul><li>Nutrition support and bowel rest </li></ul></ul><ul><ul><li>Control infection </li></ul></ul><ul><ul><li>Drainage and skin protection </li></ul></ul><ul><li>Evaluation the status and prognosis factor </li></ul><ul><li>Try pharmacotherapy </li></ul><ul><li>Surgical treatment if needed </li></ul>
  33. 33. Reference <ul><li>The Washington Manual of Surgery, 2nd ed. </li></ul><ul><li>Feldman: Sleisenger & Fordtran's Gastrointestinal and Liver Disease, 7th ed </li></ul><ul><li>Optimising the treatment of upper gastrointestinal fistulae, I González-Pinto and E Moreno González Gut 2001; 49 (Suppl 4): iv21-iv28 </li></ul><ul><li>The relevance of gastrointestinal fistulae in clinical practice: a review M Falconi and P Pederzoli Gut 2001; 49 (Suppl 4): iv2-iv10 </li></ul>
  34. 34. End Thank you for attention!!

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