Normally, fistula is defined as an abnormal communication between two epithelized surface.But enterocutaneous fistula is an abnormal communication between the skin with various parts of the gut. The ileum is the most common site of origin of enterocutaneous fistula.
Normally, fistula is defined as an abnormal communication between two epithelized surface.But enterocutaneous fistula is an abnormal communication between the skin with various parts of the gut. The ileum is the most common site of origin of enterocutaneous fistula.
Intestinal fistulas pose the greatest challenge to the General Surgeon. The presentation provides abrief guideline for management of this complex problem.
This presentation gives a fine description about stoma and ostomy. This contains the details regarding types, complications and the advices that you should give to a patient with a stoma.
Intestinal fistulas pose the greatest challenge to the General Surgeon. The presentation provides abrief guideline for management of this complex problem.
This presentation gives a fine description about stoma and ostomy. This contains the details regarding types, complications and the advices that you should give to a patient with a stoma.
Flu Vaccine Alert in Bangalore Karnatakaaddon Scans
As flu season approaches, health officials in Bangalore, Karnataka, are urging residents to get their flu vaccinations. The seasonal flu, while common, can lead to severe health complications, particularly for vulnerable populations such as young children, the elderly, and those with underlying health conditions.
Dr. Vidisha Kumari, a leading epidemiologist in Bangalore, emphasizes the importance of getting vaccinated. "The flu vaccine is our best defense against the influenza virus. It not only protects individuals but also helps prevent the spread of the virus in our communities," he says.
This year, the flu season is expected to coincide with a potential increase in other respiratory illnesses. The Karnataka Health Department has launched an awareness campaign highlighting the significance of flu vaccinations. They have set up multiple vaccination centers across Bangalore, making it convenient for residents to receive their shots.
To encourage widespread vaccination, the government is also collaborating with local schools, workplaces, and community centers to facilitate vaccination drives. Special attention is being given to ensuring that the vaccine is accessible to all, including marginalized communities who may have limited access to healthcare.
Residents are reminded that the flu vaccine is safe and effective. Common side effects are mild and may include soreness at the injection site, mild fever, or muscle aches. These side effects are generally short-lived and far less severe than the flu itself.
Healthcare providers are also stressing the importance of continuing COVID-19 precautions. Wearing masks, practicing good hand hygiene, and maintaining social distancing are still crucial, especially in crowded places.
Protect yourself and your loved ones by getting vaccinated. Together, we can help keep Bangalore healthy and safe this flu season. For more information on vaccination centers and schedules, residents can visit the Karnataka Health Department’s official website or follow their social media pages.
Stay informed, stay safe, and get your flu shot today!
Knee anatomy and clinical tests 2024.pdfvimalpl1234
This includes all relevant anatomy and clinical tests compiled from standard textbooks, Campbell,netter etc..It is comprehensive and best suited for orthopaedicians and orthopaedic residents.
Title: Sense of Taste
Presenter: Dr. Faiza, Assistant Professor of Physiology
Qualifications:
MBBS (Best Graduate, AIMC Lahore)
FCPS Physiology
ICMT, CHPE, DHPE (STMU)
MPH (GC University, Faisalabad)
MBA (Virtual University of Pakistan)
Learning Objectives:
Describe the structure and function of taste buds.
Describe the relationship between the taste threshold and taste index of common substances.
Explain the chemical basis and signal transduction of taste perception for each type of primary taste sensation.
Recognize different abnormalities of taste perception and their causes.
Key Topics:
Significance of Taste Sensation:
Differentiation between pleasant and harmful food
Influence on behavior
Selection of food based on metabolic needs
Receptors of Taste:
Taste buds on the tongue
Influence of sense of smell, texture of food, and pain stimulation (e.g., by pepper)
Primary and Secondary Taste Sensations:
Primary taste sensations: Sweet, Sour, Salty, Bitter, Umami
Chemical basis and signal transduction mechanisms for each taste
Taste Threshold and Index:
Taste threshold values for Sweet (sucrose), Salty (NaCl), Sour (HCl), and Bitter (Quinine)
Taste index relationship: Inversely proportional to taste threshold
Taste Blindness:
Inability to taste certain substances, particularly thiourea compounds
Example: Phenylthiocarbamide
Structure and Function of Taste Buds:
Composition: Epithelial cells, Sustentacular/Supporting cells, Taste cells, Basal cells
Features: Taste pores, Taste hairs/microvilli, and Taste nerve fibers
Location of Taste Buds:
Found in papillae of the tongue (Fungiform, Circumvallate, Foliate)
Also present on the palate, tonsillar pillars, epiglottis, and proximal esophagus
Mechanism of Taste Stimulation:
Interaction of taste substances with receptors on microvilli
Signal transduction pathways for Umami, Sweet, Bitter, Sour, and Salty tastes
Taste Sensitivity and Adaptation:
Decrease in sensitivity with age
Rapid adaptation of taste sensation
Role of Saliva in Taste:
Dissolution of tastants to reach receptors
Washing away the stimulus
Taste Preferences and Aversions:
Mechanisms behind taste preference and aversion
Influence of receptors and neural pathways
Impact of Sensory Nerve Damage:
Degeneration of taste buds if the sensory nerve fiber is cut
Abnormalities of Taste Detection:
Conditions: Ageusia, Hypogeusia, Dysgeusia (parageusia)
Causes: Nerve damage, neurological disorders, infections, poor oral hygiene, adverse drug effects, deficiencies, aging, tobacco use, altered neurotransmitter levels
Neurotransmitters and Taste Threshold:
Effects of serotonin (5-HT) and norepinephrine (NE) on taste sensitivity
Supertasters:
25% of the population with heightened sensitivity to taste, especially bitterness
Increased number of fungiform papillae
Tom Selleck Health: A Comprehensive Look at the Iconic Actor’s Wellness Journeygreendigital
Tom Selleck, an enduring figure in Hollywood. has captivated audiences for decades with his rugged charm, iconic moustache. and memorable roles in television and film. From his breakout role as Thomas Magnum in Magnum P.I. to his current portrayal of Frank Reagan in Blue Bloods. Selleck's career has spanned over 50 years. But beyond his professional achievements. fans have often been curious about Tom Selleck Health. especially as he has aged in the public eye.
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Introduction
Many have been interested in Tom Selleck health. not only because of his enduring presence on screen but also because of the challenges. and lifestyle choices he has faced and made over the years. This article delves into the various aspects of Tom Selleck health. exploring his fitness regimen, diet, mental health. and the challenges he has encountered as he ages. We'll look at how he maintains his well-being. the health issues he has faced, and his approach to ageing .
Early Life and Career
Childhood and Athletic Beginnings
Tom Selleck was born on January 29, 1945, in Detroit, Michigan, and grew up in Sherman Oaks, California. From an early age, he was involved in sports, particularly basketball. which played a significant role in his physical development. His athletic pursuits continued into college. where he attended the University of Southern California (USC) on a basketball scholarship. This early involvement in sports laid a strong foundation for his physical health and disciplined lifestyle.
Transition to Acting
Selleck's transition from an athlete to an actor came with its physical demands. His first significant role in "Magnum P.I." required him to perform various stunts and maintain a fit appearance. This role, which he played from 1980 to 1988. necessitated a rigorous fitness routine to meet the show's demands. setting the stage for his long-term commitment to health and wellness.
Fitness Regimen
Workout Routine
Tom Selleck health and fitness regimen has evolved. adapting to his changing roles and age. During his "Magnum, P.I." days. Selleck's workouts were intense and focused on building and maintaining muscle mass. His routine included weightlifting, cardiovascular exercises. and specific training for the stunts he performed on the show.
Selleck adjusted his fitness routine as he aged to suit his body's needs. Today, his workouts focus on maintaining flexibility, strength, and cardiovascular health. He incorporates low-impact exercises such as swimming, walking, and light weightlifting. This balanced approach helps him stay fit without putting undue strain on his joints and muscles.
Importance of Flexibility and Mobility
In recent years, Selleck has emphasized the importance of flexibility and mobility in his fitness regimen. Understanding the natural decline in muscle mass and joint flexibility with age. he includes stretching and yoga in his routine. These practices help prevent injuries, improve posture, and maintain mobilit
These lecture slides, by Dr Sidra Arshad, offer a quick overview of the physiological basis of a normal electrocardiogram.
Learning objectives:
1. Define an electrocardiogram (ECG) and electrocardiography
2. Describe how dipoles generated by the heart produce the waveforms of the ECG
3. Describe the components of a normal electrocardiogram of a typical bipolar lead (limb II)
4. Differentiate between intervals and segments
5. Enlist some common indications for obtaining an ECG
6. Describe the flow of current around the heart during the cardiac cycle
7. Discuss the placement and polarity of the leads of electrocardiograph
8. Describe the normal electrocardiograms recorded from the limb leads and explain the physiological basis of the different records that are obtained
9. Define mean electrical vector (axis) of the heart and give the normal range
10. Define the mean QRS vector
11. Describe the axes of leads (hexagonal reference system)
12. Comprehend the vectorial analysis of the normal ECG
13. Determine the mean electrical axis of the ventricular QRS and appreciate the mean axis deviation
14. Explain the concepts of current of injury, J point, and their significance
Study Resources:
1. Chapter 11, Guyton and Hall Textbook of Medical Physiology, 14th edition
2. Chapter 9, Human Physiology - From Cells to Systems, Lauralee Sherwood, 9th edition
3. Chapter 29, Ganong’s Review of Medical Physiology, 26th edition
4. Electrocardiogram, StatPearls - https://www.ncbi.nlm.nih.gov/books/NBK549803/
5. ECG in Medical Practice by ABM Abdullah, 4th edition
6. Chapter 3, Cardiology Explained, https://www.ncbi.nlm.nih.gov/books/NBK2214/
7. ECG Basics, http://www.nataliescasebook.com/tag/e-c-g-basics
Title: Sense of Smell
Presenter: Dr. Faiza, Assistant Professor of Physiology
Qualifications:
MBBS (Best Graduate, AIMC Lahore)
FCPS Physiology
ICMT, CHPE, DHPE (STMU)
MPH (GC University, Faisalabad)
MBA (Virtual University of Pakistan)
Learning Objectives:
Describe the primary categories of smells and the concept of odor blindness.
Explain the structure and location of the olfactory membrane and mucosa, including the types and roles of cells involved in olfaction.
Describe the pathway and mechanisms of olfactory signal transmission from the olfactory receptors to the brain.
Illustrate the biochemical cascade triggered by odorant binding to olfactory receptors, including the role of G-proteins and second messengers in generating an action potential.
Identify different types of olfactory disorders such as anosmia, hyposmia, hyperosmia, and dysosmia, including their potential causes.
Key Topics:
Olfactory Genes:
3% of the human genome accounts for olfactory genes.
400 genes for odorant receptors.
Olfactory Membrane:
Located in the superior part of the nasal cavity.
Medially: Folds downward along the superior septum.
Laterally: Folds over the superior turbinate and upper surface of the middle turbinate.
Total surface area: 5-10 square centimeters.
Olfactory Mucosa:
Olfactory Cells: Bipolar nerve cells derived from the CNS (100 million), with 4-25 olfactory cilia per cell.
Sustentacular Cells: Produce mucus and maintain ionic and molecular environment.
Basal Cells: Replace worn-out olfactory cells with an average lifespan of 1-2 months.
Bowman’s Gland: Secretes mucus.
Stimulation of Olfactory Cells:
Odorant dissolves in mucus and attaches to receptors on olfactory cilia.
Involves a cascade effect through G-proteins and second messengers, leading to depolarization and action potential generation in the olfactory nerve.
Quality of a Good Odorant:
Small (3-20 Carbon atoms), volatile, water-soluble, and lipid-soluble.
Facilitated by odorant-binding proteins in mucus.
Membrane Potential and Action Potential:
Resting membrane potential: -55mV.
Action potential frequency in the olfactory nerve increases with odorant strength.
Adaptation Towards the Sense of Smell:
Rapid adaptation within the first second, with further slow adaptation.
Psychological adaptation greater than receptor adaptation, involving feedback inhibition from the central nervous system.
Primary Sensations of Smell:
Camphoraceous, Musky, Floral, Pepperminty, Ethereal, Pungent, Putrid.
Odor Detection Threshold:
Examples: Hydrogen sulfide (0.0005 ppm), Methyl-mercaptan (0.002 ppm).
Some toxic substances are odorless at lethal concentrations.
Characteristics of Smell:
Odor blindness for single substances due to lack of appropriate receptor protein.
Behavioral and emotional influences of smell.
Transmission of Olfactory Signals:
From olfactory cells to glomeruli in the olfactory bulb, involving lateral inhibition.
Primitive, less old, and new olfactory systems with different path
Adv. biopharm. APPLICATION OF PHARMACOKINETICS : TARGETED DRUG DELIVERY SYSTEMSAkankshaAshtankar
MIP 201T & MPH 202T
ADVANCED BIOPHARMACEUTICS & PHARMACOKINETICS : UNIT 5
APPLICATION OF PHARMACOKINETICS : TARGETED DRUG DELIVERY SYSTEMS By - AKANKSHA ASHTANKAR
Basavarajeeyam is an important text for ayurvedic physician belonging to andhra pradehs. It is a popular compendium in various parts of our country as well as in andhra pradesh. The content of the text was presented in sanskrit and telugu language (Bilingual). One of the most famous book in ayurvedic pharmaceutics and therapeutics. This book contains 25 chapters called as prakaranas. Many rasaoushadis were explained, pioneer of dhatu druti, nadi pareeksha, mutra pareeksha etc. Belongs to the period of 15-16 century. New diseases like upadamsha, phiranga rogas are explained.
Ozempic: Preoperative Management of Patients on GLP-1 Receptor Agonists Saeid Safari
Preoperative Management of Patients on GLP-1 Receptor Agonists like Ozempic and Semiglutide
ASA GUIDELINE
NYSORA Guideline
2 Case Reports of Gastric Ultrasound
2. DISCUSSION
INTRODUCTION
Fistula is defined as an abnormal communication between two epithelialized
surfaces.
Enterocutaneous fistula is an abnormal communication between the skin with
various parts of the gut, for example duodenum, jejunum etc.
The word fistula means a “pipe” or “flute” in Latin.
The ileum is the most common site of origin of Enterocutaneous fistula.
3. Patients are usually systemically ill, with sepsis being a significant risk factor.
Spontaneous closure rate depend upon many factors like anatomy, etiology,
nutritional status, output from fistula.
Fluid and electrolyte imbalance, malnutrition, sepsis & related complications,
local wound excoriation are some of the known complications.
4. ETIOLOGY
Webster and Carey proposed five mechanisms of fistula formation :
1> Congenital : - Rare
- Due to the complete failure of Vitellointestinal duct to obliterate.
- Fecal matter at umbilicus after post natal slough of the stump.
2> Trauma :
- Major penetrating trauma to the abdomen may lead to ECF.
- Damage control laparotomy techniques have higher risk of
delayed ECF formation(2% to 25%).
5. 3> Infection : - Abscess or invasive intestinal infections like amoebiasis,
coccidiomycosis, tuberculosis etc.
- Intestinal perforation in ileum from tuberculosis or enteric fever
esp in 3rd world countries.
- Actinomyces infection post appendectomy.
4> Perforation or Injury with Abscess & Operative complications :
- Intra-abdominal abscess may erode into the gut & through the
skin.
- 75-85% are iatrogenic - after surgery for bowel obstruction,
cancer, or IBD
6. 5> Inflammation, Irradiation or Tumour :
- Crohn’s disease may cause ECF – post op more common
than spontaneous.
- ECF after anastomosis/appendicectomy/simple exploration
in Crohn’s disease.
- Irradiation for pelvic malignancies etc may lead to a chronic
non-healing ECF.
7. PREVENTION OF FISTULA
- Acute intra-operative perforations should be identified and closed.
- Serosal tears should be examined carefully and repaired if required.
- Aggressive interloop adhesion break-up should be avoided to prevent serosal
tears.
8. DIAGNOSIS OF PERFORATION AND FISTULA
-Post operatively anastomotic leaks/unrecognised perforations and
subsequent fistulae may manifest as instability or patient’s failure to improve.
-Fever, abdominal pain followed by exiting of intestinal contents from drain or
incision site.
-Occasionally,heavily purulent discharge may mask an ECF like in enteric
perforations.
-Activated charcoal or indigo carmine by mouth can help in diagnosing ECF.
- Intraluminal instillation of methylene blue and saline or direct endoscopy helps
to identify small perforations.
9. STAGING AND CLASSIFICATION
1. Anatomical Classification : Internal or External fistula(ECF).
- Internal fistulae are named after the structures it communicates
like gastrocolic, jejunoileal, aortoenteric fistula.
- External fistulae like gastric, duodenal, jejunal, ileal or fecal.
2. Physiologic classification : Based on output
- High-output > 500 cc/day (Difficulties in fluid management and
skin care)
- Moderate-output 200-500 cc/day
- Low-output < 200 cc/day (Usually colonic)
11. STABILIZATION
> The first step of management is the resuscitation and stabilization of the patient.
> Needs to be accomplished within the first 24 to 48 hours of management.
> Initial efforts directed towards intravenous fluid resuscitation, control of infection,
protection of surrounding skin & measuring and replacing ongoing losses.
> Attention should also be given to any intra-abdominal/subcutaneous abscesses
& if present they should be drained.
12. A. RESUSCITATION
> Restoration of normal circulating blood volume and correction of electrolyte
and acid-base imbalances are a top priority.
>Rehydration usually requires isotonic fluid(NS/RL) until the patient is euvolemic.
> Strict input and output measurements are essential and CVP monitoring
and urinary catheterisation are especially helpful.
> Ongoing fluid losses should be fully replaced and electrolyte imbalances
must be corrected.
13. RESUSCITATION CONTD..
> Enterocutaneous fistulae are usually associated with hypokalemia and
metabolic acidosis, which require correction.
> Electrolyte measurement of the fistula output helps in planning of
replenishment of ongoing losses.
> Urine output should be restored to greater than 0.5mL/kg/hr.
> Requirement of blood transfusion depends upon overall hemodynamic
status, patient’s oxygen carrying capacity and oxygen delivery.
14. B. NUTRITION
> In 1972, Roback and Nicholoff reported closure of 73% of enteric fistulae
in adequately nourished patients, as against 19% in inadequate ones.
> Nutritional support needs to begin as soon as the patient is stabilized.
> Nutrition can be given by parenteral or enteral route,based on the anatomy
of the fistula.
> Its advisable to provide atleast a part of the daily nutritional requirement
through enteral route.(Even 25% of daily requirement given enterally,
can help reap its benefits)
15. NUTRITION CONTD..
> Nutrition via the enteral route helps in maintaining the intestinal mucosal
barrier, more efficacious delivery of nutrients, stimulating hepatic protein
synthesis.
> WHO’s ORS (40g/L of glucose, 90 mEq/L of Na, 20 mEq/L of K) should be
given when oral intake is possible.
> In proximal fistulae, the enteral feeding tube may be entered beyond the
fistula to provide enteral nutrition(fistuloclysis).
> It is advisable to enter feeding tube beyond ligament of Treitz for a gastric
or duodenal fistula.
16. NUTRITION CONTD..
> Enteral feeds of highly absorbable, low-residue nutrients can be given if even
4ft of functional bowel exists in between ligament of Treitz and the proximal
end of the fistula.
> During the time the enteral nutrition is increasing, patient should be
supplemented with TPN.
> TPN is also given in patients who do not tolerate enteral feeds or have
long standing ileus or before fistulous tract is well established.
17. NUTRITION CONTD..
TYPE OF FISTULA
CALORIE REQ
PROTEIN REQ
Low Output
30-35 kcal/kg/day
1-2 gm/kg/day
High Output
45-50 kcal/kg/day
1.5-2.5 gm/kg/day
> Twice the daily requirement of vitamins, trace elements, zinc and upto 10 times
the daily requirement of Vitamin C should be provided.
> Short turnover proteins like retinol-binding protein, prealbumin, ferritin can be
used to monitor the weekly efficacy of protein delivery. [Alb half life is 20 days].
> Mortality rate of 42% with alb <2.5 mg/dl vs 0% if >3.5 mg/dl.
18. C. CONTROL OF SEPSIS AND FISTULA EFFLUENT
> Persistant fever, tachycardia and leukocytosis along with failure to improve
adequately points towards possible sepsis or abscesses.
> May require surgical drainage of abscess,if any along with adequate antibiotic
cover.
> Local skin care and prevention of skin excoriation by using stomahesive paste
or aluminium paint etc along with stoma bags.
> Excessive fistula output can be controlled by nasogastric tube placement,
withdrawal of oral feeds, initiation of parenteral nutrition or placement of
sump suction catheter as described by Suripaya and Anderson,1971.
19. C. CONTROL OF SEPSIS AND FISTULA EFFLUENT CONTD..
> Vacuum assisted closure [VAC] device drainage system maybe used too.
> Due to the negative pressure application, VAC device helps to control drainage,
minimizes the size of the abdominal wound, reduces frequency of dressing
and protects the skin while helping to promote fistula healing.
> For majority of ECFs, VAC devices have become the method of choice for
controlling fistula drainage and skin protection.
20.
21. D. PHARMACOLOGICAL SUPPORT
> Somatostatin analogue Octreotide, at doses of 100 – 250 mcg TDS reduces
fistula output by 40 – 60% by the end of 24 hrs.
> Should be discontinued if ineffective for 48 hrs as it has side effects like
hyperglycemia, elevated cholesterol and reduced bowel motility.
> Octreotide and TPN seem to have a synergistic effect on reduction of effluent
volume and improvement in fistula closure rates.
> Proton-pump inhibitors and H2 receptor antagonists also help reduce fistula
output especially in proximal fistulas.
22. D. PHARMACOLOGICAL SUPPORT CONTD..
> Cyclosporine in doses of 4 mg/kg/day for 6 – 10 days followed by oral doses
of 8 mg/kg/day helps to treat refractory fistulae associated with Crohn’s disease.
> Other drugs used include Tacrolimus, Azathioprine, 6-MP, Infliximab(mAb TNFα).
> Infliximab administered at a dose of 5 mg/kg iv at 0,2,6 weeks helped in partial
resolution of 68% of multiple lesions and complete closure in 55% of patients.
> Complications include URTI, headache, fatigue etc.
23. INVESTIGATIONS
> Investigations are done for the next 7 to 10 days following stabilization.
> They are carried out to determine the presence and location of the fistula,
its cause and presence of comorbidities.
> Oral administration of Indigo Carmine/ Charcoal helps in diagnosing the
presence of a fistula,but not its location, cause or anatomy.
> USG abdomen helps in locating intra-abdominal abscesses, apart from
helping in performing guided aspiration of intra-abdominal collections.
24. > Fistulography helps in defining the length & width of the fistula, its anatomical
location, the presence of any distal obstructions etc.
> It can be performed by entering a small cathter into the fistulous tract and then
injecting the water-soluble contrast under fluoroscopy.
> Fistulogram should be performed before an upper GI series or CT scan with
oral contrast or contrast enema as it poses difficulty in interpretation.
> Fistulography should be followed up with a complete contrast study of the
GI tract.
25.
26. CT scan of the abdomen with IV and oral contrast is highly sensitive and specific
for locating the fistula, defining its anatomy, commenting on the gut surrounding
fistula, presence of any intra-abdominal abscess or distal obstruction/pathology.
CT scan is highly recommended for duodenal and pancreatic fistula.
CT scan can be therapeutic by helping in CT-guided aspiration of intra-abdominal
abscesses,if any.
Endoscopy may also be used occasionally though its principal use is in internal
fistulas.
Endoscopy is usually delayed till acute inflammation gets reduced.
27. DECISION
FACTORS RESPONSIBLE FOR SPONTANEOUS CLOSURE
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, Transferrin >200
Malnourished, Transferrin
<200
Sepsis
Absent
Present
State of bowel
Intestinal continuity, absence of
obstruction
Diseased adjacent bowel,
Distal obstruction, Abscess,
Discontinuity, Irradiation
Fistula characteristics Tract >2 cm, Defect <1cm
Tract <1cm, Defect >1cm
Miscellaneous
Referred from outside
institution
Original operation at same
institution
28. > Reber et al reported that more than 90% of small intestinal fistula which
closed spontaneously,did so within a month.
> Spontaneous closure rates dropped to less than 10% after 2 months and
none after 3 months.
> Factors possibly responsible for failure of spontaneous closure are:
a. Foreign Body
b. Radiation
c. Inflammation/ infection
d. Epithelialisation
[F-R-I-E-N-D-S]
e. Neoplasm
f. Distal intestinal obstruction
g. Steroids.
29. DEFINITIVE THERAPY
> Majority (80-90%) will close within 6 weeks with conservative management.
> Surgery between 10 days and 6 weeks post-op will encounter the worst
adhesions.
> Preferably wait upto 6 weeks before open exploration and repair of defect,
but in case of faecal fistula, due to intense inflammation, it is prudent to wait
upto 10-12 weeks.
> The patient should,by then, be nutritionally optimized, patient should not be septic
and patient should be vitally stable.
30. > Definitive operative correction remains the final step in the treatment of
non-healing small intestinal fistulas.
> In majority of the cases, preferred operation is resection of the involved segment
with primary end-to-end anastomosis. (Reber HA, 1978)
> However if primary anastomosis is not possible,then both the proximal and
distal ends of intestine are exteriorized.
> In case the fistula is deemed inappropriate for resection, such as when it
develops after a deep pelvic procedure, staged approach involving bypass
should be considered.
31. > In a staged procedure, the fistulous segment is left in-situ or the ends are
exteriorized as mucous fistula and the afferent and efferent bowel loops
are anastomosed to restore intestinal continuity.
> The staged procedure is completed when the fistula segment is removed at
a later date,although it may not always be possible.
> Enteroatmospheric fistulas, which are associated with large abdominal defects
are very difficult to manage and are associated with high mortality rates.
> Mortality rates may vary from 20% to 60%. (Schein M, Decker GA 1991)
> Enteroatmospheric fistulas usually require multiple staged operations.
33. > Enterocutaneous fistula treatment is complicated due to various factors like
open abdominal wound leading to desiccation of gut loops, presence of
multiple fistulous openings, dressings adhering to the gut loops etc.
> VAC devices are used initially to approximate the large abdominal defect
along with isolation of the fistula(s) by ostomy bags.
> After proper granulation tissue formation, the stabilized patient can be
considered for SSG, if his nutritional status is favourable.
> After 6 to 12 months recovery time to replenish protein and calorie stores,
resection of the fistula as definitive therapy can be provided to the patient.
> Musculocutaneous flaps, abdominal wall reconstruction by component
separation technique, use of prosthetic materials,esp biologics may also
be necessary. (human acellular dermal matrix)
34.
35. > In 1995, Ho HS and Frey CF used primary closure of gastric fistula with
delayed external drainage as treatment for gastric fistulas.
> If the gastric fistula defect is too large to allow primary closure,then a
Roux-en-Y gastrojejunostomy may be done.
> Duodenal fistulas are usually treated with tube duodenostomy or Roux-en-Y
duodenojejunostomy.
> A feeding jejunostomy distal to the enteroenterostomy should always be
considered.
38. CONCLUSION
> Enterocutaneous fistulas are abnormal communication between the gut
and skin.
> Majority of the ECF are due to iatrogenic causes (70-85%). Others include
trauma, congenital causes. Spontaneous ECF may arise due to Crohn’s
disease.
> Malnutrition, Electrolyte imbalances, acid-base imbalances and sepsis are
the major causes of mortality in ECF.
> After initial stabilization of the patient by resuscitation( fluid, electrolytes,
blood transfusions etc), the patient is subjected to various investigations
to determine the location& anatomy of fistula, presence of distal obstruction
etc.
39. > Enteral nutrition is always preferable to parenteral nutrition provided the
patient tolerates enteral feeds.
> Local wound care by application of ostomy bag and pastes are essential.
> Drainage of intra-abdominal abscesses, treatment of sepsis is of utmost
importance.
> After proper optimization, patient undergoes definitive therapy which
includes resection of the fistulous segment of the gut.
> ECF with large abdominal defects may require VAC devices/ biologic mesh
SSG to help close the defect.