The document discusses enterocutaneous fistulas (ECF), abnormal connections between the gastrointestinal tract and skin. ECF are commonly caused by surgery (75-85%) and the ileum is the most common origin site. Diagnosis is clinical with imaging to identify anatomy and rule out abscesses. Treatment involves stabilization, sepsis control, nutrition, and identifying the fistula anatomy. Most ECF close spontaneously with conservative management including nutrition support. Surgery is considered if the fistula does not close within 3-6 months.

1. Dr. Simba Fidel

2.  Introduction
 Classification
 Etiology & Risk Factors
 Clinical Features
 Diagnosis
 Management

3.  A fistula is an abnormal connection between two epithelialized hollow spaces or
organs.
 Enterocutaneous fistula is an abnormal communication between the skin with
various parts of the gut.
 Fistula means “pipe” or “flute” in latin.
 The ileum is the most common site of origin of ECF.

4.  ECF are classified according to source, output volume, and etiology.
 By source: i.e gastro-, duodeno-, jejuno-, ileo-, colo-, recto-
 By output volume;
 Low output; <200ml/day
 Moderate output; 200ml-500ml/day
 High output; >500ml/day
 By Etiology

5.  Webster and Carey proposed 5 general mechanisms for intestinal fistula formation;
1. Congenital: complete failure of the vitellointestinal duct to obliterate, which results in a
ECF to the umbilicus
2. Trauma: enteroatmospheric fistulas after damage control laparotomy
3. Infection: Actinomyces is a common cause of ECF after appendicectomy.
4. Perforation or injury with abscess: Iatrogenic
5. Infammation, Irradiation or tumor

6.  (ECF) are commonly iatrogenic (75-
85%) and are the most common type of
small bowel fistula

7.  Iatrogenic enterocutaneous fistulas usually become clinically evident between the 5th
and 10th postop days.
 Fever,
 leukocytosis,
 prolonged ileus,
 abdominal tenderness, and
 wound infection are the initial signs.
 An enteric fistula can be distinguished from a wound infection by the presence of bile
in the wound.

8.  The diagnosis of an enterocutaneous fistula is clinical.
 Abd CT: the most useful initial test, with enteral contrast
 GI series; eg Enteroclysis, or barium follow-through
 Fistulogram

9.  The treatment of enterocutaneous fistulas should proceed through an orderly
sequence of steps;
i. Stabilization
ii. Sepsis control
iii. Skin care
iv. Nutrition
v. Anatomy identification
vi. Decision and definitive management

10. 1. Stabilization;
 In the first 24hr-48hr
 Aggressive correction of hypovolemia and electrolyte loss should occur early,
 Ongoing fluid losses from moderate-output upper gastrointestinal fistulas should be
replaced with saline and potassium supplementation with serial measurements of serum
electrolytes
 Duodenal or pancreatic fistulas may require bicarbonate replacement to prevent
metabolic acidosis.

11. 2. Sepsis Control;
 Patients who have diffuse peritonitis or evidence of free gastrointestinal perforation on
imaging studies require urgent surgical exploration.
 Diversion of the fecal stream by ostomy is often required and is the preferred approach.
 Hemodynamically stable patients without diffuse peritonitis should undergo abd(CT) to
identify any intra-abdominal source of sepsis; i.e abscess
 Antibiotic management in nonseptic patients with an enterocutaneous fistula is controversial

12. 3. Skin care;
 Wound bags; i.e
ostomy bags
 NPWT

13.  Pharmacological treatment;
 Anticarthatics; eg Loperamide and diphenoxylate-atropine (Lomotil) for diarrhea and high
output fistulas
 Somatostatin analogs; eg Octreotide (SC/IM 50mcg-100mcg q 8-12hrly)
 Antisecretories; eg PPIs and Histamine-2 receptor antagonists
 Cholestyramine — For the uncommon bilioenteric fistula (eg, biliary-
colonic), cholestyramine can be tried.

14. 4. Nutrition;
 73% of enteric fistulae closes spontaneously in adequately nourished patients,
 Nutritional support needs to begin as soon as the patient is stabilized
 Parenteral vs enteral depending on the anatomy of the fistulanutrition via enteral route
helps in maintaining the intestinal mucosal barrier,
 It is advisable to provide at least part of daily nutritional requirement via enteral. (25%)
 In proximal fistula, the enteral feeding tube may be entered beyond the fistula to provide
enteral nutrition

15.  TPN is given in patients who do not tolerate enteral feeds or have longstanding ileus
or before fistulous tract is well established.
 For Low output  caloric req of 30-35kcal/kg/day, & 1-1.5g/kg/d
 High output  45-50kcal/kg/day, & 1.5-2.5g/kg/d of protein intake
 Vitamins, trace elements, zinc and upto 10times the daily requirements of VitC should
be provided
 Mortality rate of 42% with albumin <2.5mg/dl, vs 0% if > 3.5mg/dl
 N.B: for high output NGT, put NPO, and start TPN.

16.  Non-operative fistula closure;
1. Covered enteric stents
2. Endoscopic clipping
3. Fistula plugs
 Fibrin sealant

17.  80-90% will close within 5-6weeks with conservative management
 Surgery done btn 10days and 6wks post-op will encounter the worst adhesions
 Most surgeons would pursue 2 to 3 months of conservative therapy before considering
surgical intervention.
 Specialized centers often delay the definitive surgery for 6 to 12 months
 The patient should by then be nutritionally optimized, should not be septic

18.  Resection of the intestinal segment, fistula tract and the adjacent part of the involved
structure.
 Absence of extensive infection or inflammation=> Primary anastomosis of the divided
intestinal segments and reestablish GI continuity
 In presence of extensive infection the divided intestinal segments are exteriorized
and
 Staged procedure is performed after the infection and inflammation subsides.

19.  Over 60% of intestinal fistulas close spontaneously.
 Operative repair was associated with a 30-day mortality of approximately 4% and
a 1-year mortality of 15%.
 Morbidity was over 80%.
 First attempt at surgical repair was successful in 70% of cases

20.  Acute intra-operative perforations; early identification and closure
 Serosal tears should be repaired
 Aggressive adhesiolysis should be avoided to prevent serosal tears

21.  ECF are abdnormal are abnormal communication btn the gut and skin
 Majority of ECF are due to iatrogenic causes (70-80%). Others include trauma,
congenital and the FRIEND mnemonic
 Diagnosis is clinical. Imagings are adjunct for anatomy identification and ruling out
intra abdominal abscesses
 Drainage of intra abdominal abscess and treatment of sepsis is of utmost importance.
 Most ECF will close spontaneously within 5-6wks, if not a definitive treatment can be
decided on.

22.  Schwarts Principles of Surgery
 Uptodate.com
 COSECSA MCS notes 2021