Gastrointestinal Fistula

1. GASTRO-INTESTINAL
Fistulas
Dr Phillipo Leo Chalya
M.D. [Dar]; M.MED surg [Mak]
Surgeon Specialist - BMC

2. Outline
 Definition
 Etiology
 Classifications
 Pathophysiology
 Clinical presentation
 Workup
 Management
 Complications
 Prognosis
 Conclusion

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

4. AEtiology
 Congenital
 Acquired

5. Congenital
 Tracheo-oesophageal fistula

6. Acquired
 Inflammatory
 Neoplastic
 Post-traumatic
 Infective
 Vascular

7. Inflammatory
 Crohn’s disease
 Diverticular disease
 Peptic ulceration
 Necrotizing pancreatitis
 Appendicitis

8. Neoplastic
 Colon cancer
 Ovarian cancer
 Small bowel malignancies
 Rectal cancer

9. Post-traumatic
 Surgery [Account for > 85-90% of all GI fistula
causes]
 Radiation
 Penetrating injury

10. Infective
 Intestinal TB
 Actinomycosis
 Typhoid fever

11. Vascular
 Mesenteric ischemia

12. Classification
 Aetiological Classification
 Anatomical Classification
 Morphological Classification
 Physiological Classification
 Pathological Classification

13. Aetiological Classification
 Congenital fistula
 Born with the fistula
 Acquired fistula
 Occurring later in life

14. Anatomical Classification
 According to the location of the fistula
 According to the organ involved
 According to the type of the fistula

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]

23. Clinical presentation
 History
 Physical examination
 General examination
 Systemic examination

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.

27. Physical examination
 General examination
 Systemic examination

28. General examination
 Wasting / malnourished
 Dehydrated
 Shock
 Anaemia
 ±Febrile
 Etc

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

30. WORKuP
 Lab studies
 Radiological studies
 Endoscopic studies

31. Lab studies
 Hemoglobin levels
 FBP + ESR
 Serum electrolytes
 Serum creatinine

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

33. Endoscopic studies
 Cystoscopy
 To rule out colo-vesical fistula

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

41. Phase II. Investigations
 As for work up above

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.

48. Complications
 Fluid and electrolytes imbalance
 Sepsis
 Malnutrition

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