Fistula intestinal enjoy kro

1. INTESTINAL FISTULA
Naqvi Syed Noor ul Hassan
Group # 11
Subject # surgical disease

2. A fistula (a term derived from the Latin word for pipe)
is an abnormal connection between 2 epithelialized
surfaces that usually involves the gut and another
hollow organ, such as the bladder, urethra, vagina, or
other regions of the gastrointestinal (GI) tract.

3. ■ Fistulas may also form between the gut and the
skin or between the gut and an abscess cavity.
Rarely, fistulas arise between a vessel and the gut,
resulting in profound GI bleeding, which is a
surgical emergency.

4. ■ Most GI fistulas (75%-85%) occur as a complication
of abdominal surgery. However, 15%-25% of fistulas
evolve spontaneously and are usually the result of
intra-abdominal inflammation or infection.
Regardless of their cause, fistulas have a
tremendous impact on patients and society.
■ Increased morbidity and mortality rates, greater
health care costs for diagnosis and treatment,
prolonged hospital stays, and delayed return to work
are just a few direct consequences of this condition

5. ■ Fistulas were formerly associated with considerable
mortality rates. In the decades following the 1960s,
however, the introduction of intensive care units
(ICUs) and parenteral nutrition lowered the mortality
rate to approximately 20%; however, prolonged
hospital stays and the high cost of medical and
surgical care remained unchanged.

6. Classification
■ Several classification systems for fistulas exist, none
of which are used exclusively. The three most
commonly used classification systems are based on
anatomic, physiologic (output volume), and etiologic
characteristics.Used in combination, these
classifications can help to provide an integrated
understanding and optimal management scheme
for the fistula

7. ■ Enterocutaneous
■ Enteroenteric
■ Enterovesical
■ Nephroenteric
■ Enterovaginal
■ Aortoenteric

8. ■ Anatomically, the fistulas are named according to
their participating anatomic components, and they
can be divided into internal and external fistulas.
Internal fistulas connect the GI tract with another
internal organ, the peritoneal space, the
retroperitoneal space, the thorax, or a blood vessel.
■ External fistulas, which commonly occur
postoperatively, are abnormal connections between
the GI tract and the skin.

9. Risk factors
■ Surgical procedures to treat cancer, inflammatory
bowel disease (IBD), lysis of adhesions, or peptic
ulcer disease
■ IBD (eg, Crohn disease and ulcerative colitis)
■ Diverticular disease
■ Radiation
■ Malignancy (especially gynecologic and pancreatic)
■ Appendicitis

10. ■ Perforation of duodenal ulcers
■ Abdominal trauma (eg, gunshot wounds, stabbing
[sharp trauma]), or motor vehicle accident [blunt
trauma])
■ Aortic aneurysm, infected aortic graft, or previous
abdominal aortic surgery
■ Contrary to common belief, fistulas do not
necessarily develop as a consequence of downstream
stenosis of the intestine

12. Gastric fistulas
■ Gastric fistulas are iatrogenic in most cases (85%).
The other cases are usually a consequence of
irradiation, malignancy, inflammation, and
ischemia. Anastomotic leak after a gastric resection
for cancer, peptic ulcer disease, or bariatric surgery
can lead to leakage of intestinal or gastric juices
■ Which initiates a cascade of events: localized
infection, abscess formation, and, possibly, abscess
and fistula formation.

13. Small bowel fistulas
■ Nearly 80% of small bowel fistulas result from
complications of abdominal surgery. These fistulas
may occur from disruption of the anastomotic suture
line, inadvertent iatrogenic enterotomy, or small
bowel injury at the time of closure.
■ Inadequate blood flow from devascularization or
tension at the anastomotic suture lines,
anastomosis of diseased bowel, or perianastomotic
abscess may compromise the integrity of surgical
anastomoses.

14. Fistulas in Crohn disease
■ Crohn disease, a chronic inflammatory bowel
disease that was once considered rare in the
pediatric population, is currently recognized as one
of the most important chronic diseases that affect
children and adolescents.
■ Crohn disease, malignancy, peptic ulcer disease, and
pancreatitis spontaneously cause 10%-15% of small
bowel fistulas

15. ■ In patients with Crohn disease, fistulas arise from
aphthous ulcers that progress to deep transmural
fissures and inflammation, subsequently leading to
adherence of the bowel to adjacent structures that
eventually penetrate other structures.
Microperforation with abscess formation leads to
subsequent macroperforation into the adjacent
organ or skin, resulting in fistula formation

16. ■ Crohn fistulas are more often internal and less
commonly external (to the skin). Ileosigmoid fistulas,
usually a complication of a diseased terminal ileum
that invades the sigmoid colon, are the most
common type of fistula between two loops of bowel.
Enteroenteric, gastrocolic, duodenocolic,
enterovesical, rectovaginal

17. ■ And perianal fistulas are other potential complications of
Crohn disease. Perianal fistulas are the most common
external fistulas in patients with Crohn disease

18. Colonic fistulas
■ Colonic fistulas are primarily a consequence of intra-
abdominal inflammation but can also occur after surgical
intervention for an inflammatory condition. IBD,
diverticulitis, malignancy, and appendicitis (especially with
the presence of an appendiceal abscess requiring
percutaneous drainage) are the most common
inflammatory conditions that lead to colonic fistulas.

19. Aortoenteric fistulas
Aortoenteric fistulas most commonly occur secondarily,
usually after the surgical placement of a graft.
Aortoenteric fistulas can develop in the following ways:
A suture line, most commonly the proximal one, can
communicate with the intestinal tract

20. ■ A suture line pseudoaneurysm can erode into
adjacent bowel
■ Erosions can occur in the graft close to the suture
line, resulting in the midportion of the graft eroding
into adjacent bowel; conversely, primary aortoenteric
fistulas almost always result from erosion of the
aneurysmal or infected aorta into surrounding areas,
most commonly the bowel

21. Epidemiology
In developed countries, Crohn disease is the most
common cause of spontaneous fistula formation. In
their lifetime, as many as 40% of patients with Crohn
disease develop a fistula, most often an external or a
perianal one.
The incidence of fistula formation in patients with
diverticulitis is much lower.

22. Fistula formation complicates diverticulitis in 1%-12%
of patients. Colovesical fistulas in men and colovaginal
fistulas in women are the most common types of
fistulas in this population.
Fistulas can complicate radiation therapy weeks to
years after treatment. Radiation therapy for
malignancy is associated with fistula formation in
approximately 5%-10% of patients

23. Internationally, the frequency of various types of
fistulas may vary in correlation with their prevalence in
different populations.
For example, the prevalence of fistulas secondary to
Crohn disease may be less prevalent in Africa primarily
because the disease is less prevalent in that
population.

24. ■ Racial differences in patients with fistulas generally
parallel those of the underlying disease or condition
that predisposed persons in a specific racial
population to developing fistulas. For example, since
Crohn disease is more common in whites, patients
with Crohn disease who develop fistulas are more
likely to be white.

25. ■ With regard to sex-related prevalences, colovesical
fistulas are more common in men and in women
who have undergone a hysterectomy. Colovaginal
fistulas, of course, occur only in women. Otherwise,
fistulas are equally prevalent in males and females

26. Symptoms
■ Symptoms caused by fistulas that involve two
segments of the bowel vary depending on the
location of the fistula and the amount of bowel
bypassed.
■ Enteroenteric fistulas in which only a short segment
of bowel is bypassed may be asymptomatic
■ Ileosigmoid fistula may cause diarrhea, weight loss,
or abdominal pain

27. ■ Patients with gastrocolic fistulas may present with
symptoms of
abdominal pain,
weight loss,
feculent belching.

28. ■ In patients of Enterovesical fistula and colovesical
fistula symptom are :
■ Pneumaturia,
■ fecaluria,
■ recurrent urinary tract infections

29. ■ Patients with rectovaginal and anovaginal fistulas
may be asymptomatic and present with symptoms
only when the bowel movements are more liquid.
■ Possible symptoms include inadvertent passage of
stool or gas, dyspareunia, and perineal pain
■ Patients with external fistulas generally present with
symptoms of drainage through the skin. Patients
with aortoenteric fistulas may report rectal bleeding.

30. Causes

31. ■ Trauma
■ Operative trauma is the most common cause of
enterocutaneous fistula formation. Inadvertent
enterotomies [4] and leakage from intestinal
anastomoses result in leakage of intestinal contents
with abscess formation. The abscess erodes through
the abdominal wall, commonly at the surgical
incision site or drainage site.

32. ■ Infection
■ Intestinal infections that erode through the wall
cause an abscess and may lead to fistula formation
between the intestine and an adjacent viscus, a solid
organ, or the exterior of the body. Amebiasis,
actinomycosis, tuberculosis, Salmonella infection,
coccidiomycosis, and cryptosporidiosis can all result
in periluminal abscesses and fistulas

33. ■ Inflammation
■ Crohn disease leads to ulceration and chronic
transmural inflammation of the intestinal wall. The
serosa of a healthy viscus adheres to the diseased
intestine. Adjacent bowel loops, bladder, colon, and
vagina are commonly involved. Inflammation
gradually progresses to microabscess formation and
internal perforation in the ulcerated areas

34. ■ Enteroenteric, enterovesical, enterovaginal, and
perineal fistulas develop frequently in patients with
Crohn disease.
Ulcerated bowel-wall perforation may also lead to
interloop abscess formation. The abscess may erode
into adjacent bowel loops, resulting in fistula
formation.

35. ■ Radiation injury and malignancy
■ Long-term radiation injury to the intestine leads to
ischemic changes in the intestinal wall. Erosions and
dense adhesions between bowel loops develop,
which can result in enteroenteric fistula formation.
Similarly, degeneration of malignant tumors of the
intestine or solid abdominal structures can lead to
erosion into adjacent bowel loops, leading to
fistulas.

36. ■ Congenital
■ Complete failure of the omphalomesenteric duct to
obliterate results in an enterocutaneous fistula at
the umbilicus (see the image below). This is a rare
congenital form of enterocutaneous fistula. The
appearance of feculent material at the umbilicus
suggests the diagnosis, and surgical resection of the
patent duct is performed.

37. Differential diagnosis
■ Abdominal Abscess
■ abdominal Aortic Aneurysm
■ Abdominal Incisions and Sutures in Gynecologic
Oncological Surgery
■ Aortitis
■ Appendicitis
■ Blunt Abdominal Trauma
■ Colon Cancer

38. ■ Urinary Tract Infection (UTI) and Cystitis (Bladder
Infection) in Females
■ Diverticulitis
■ Enterovesical Fistula
■ Inflammatory Bowel Disease
■ Large-Bowel Obstruction
■ Malabsorption
■ Penetrating Abdominal Trauma
■ Peptic Ulcer Disease
■ Small Intestinal Diverticulosis

39. Diagnosis
■ Enterocutaneous fistulas
■ Excessive drainage via the abdominal incision or via
operatively placed drainage catheters is often the
first indicator of a postoperative enterocutaneous
fistula. The drainage typically consists of obvious
intestinal contents or fluid with bile staining

40. ■ The presence of purulent fluid may disguise the
character of the intestinal fluids, leading to initial
misdiagnosis of a wound infection. The presence of
gas bubbles in the wound or drain output also
indicates an intestinal connection.

41. The skin surrounding the area of the fistula is
erythematous and indurated and may be fluctuant if an
underlying collection is present.
Clinical signs of sepsis (eg, fever, tachycardia, chills)
are common when the fistula is associated with
undrained intraperitoneal abscesses and infection of
the soft tissue of the abdominal wall

42. Enteroenteric fistula
Radiologic studies are often used for initial diagnosis
of enteroenteric fistulas. The studies are obtained to
evaluate intestinal symptoms or abdominal pain.
Diarrhea, abdominal pain, weight loss, and fever are
common symptoms associated with enteroenteric
fistulas of all etiologies.

43. Enterovesical fistula
Urinary tract contamination with intestinal organisms
leads to the development of urinary symptoms in more
than 80-90% of patients with enterovesical fistulas.
The common presenting urinary symptoms include
bladder irritability, dysuria, pyuria, fecaluria, and
pneumaturia.

44. Nephroenteric fistulas
Typically, nephroenteric fistulas (see the image below)
develop slowly because of chronic renal disease; thus,
the most common initial symptom is chronic urinary
tract infection (UTI). In contrast, nephroenteric fistulas
that occur from penetrating trauma often present early
with symptoms of UTI.

45. Enterovaginal fistulas
Purulent or feculent vaginal discharge is the most
common presentation of enterovaginal fistula (see the
image below). Sepsis from associated intraperitoneal
abscesses is common, and these patients experience
abdominal pain, fever, and chills. Patients may develop
a UTI as a consequence of bacterial contamination
ascending the urethra.

46. Aortoenteric fistula
Aortoenteric fistulas (see the image below) present
with gastrointestinal (GI) bleeding because of a direct
communication between enteric lumen (commonly
duodenum) and arterial lumen. Initial herald or
sentinel bleeding (eg, hematemesis, hematochezia,
melena) is commonly mild and self-limited. Often,
weeks to months later, the patient has an episode of
massive GI hemorrhage.

47. Pathophysiology
■ The intestinal bacterial flora leads to contamination and
eventual development of sepsis. The local effect of
intestinal fluid can be damaging or corrosive to the
nonintestinal tissue, leading to breakdown, erosions, and
loss of normal organ or organ system function.

48. ■ Small-bowel fistulas can be classified according to
the anatomic structures involved, the etiology of the
disease process leading to fistula formation, and the
physiologic output (primarily for enterocutaneous
fistulas),as follows:
■
■ Anatomic classifications define the sites of fistula
origin, drainage point, and whether the fistula is
internal or external

49. ■ Physiologic classifications rely on fistula output in a
24-hour period
■ Etiologic classifications (eg, malignancy,
inflammatory bowel disease, or radiation) define the
associated disease entity leading to the
development of the fistula
■ Each type of classification system carries specific
implications regarding the likelihood of spontaneous
closure, prognosis, operative timing, and
nonoperative care planning.

50. Medical therapy
■ Initial treatment of intestinal fistulas is medical, including
resuscitation, control of sepsis, local control of fistula
output, nutritional support, pharmacologic management,
and radiologic investigations. The final therapeutic step, if
necessary, is definitive surgery to restore gastrointestinal
(GI) tract continuity

51. ■ Most patients with GI fistulas experience significant
fluid and electrolyte imbalances. Carefully monitored
replacement of the losses is essential and is often
paired with central venous monitoring to accurately
estimate fluid deficits.
■ Uncontrolled sepsis is a major cause of mortality in
patients with small-bowel fistulas.

52. ■ Tachycardia, persistent fever, and leukocytosis
indicate the presence of infection associated with
the fistula. Patients are treated with broad-spectrum
antibiotics and local drainage of abscesses
■ Surgical drainage may be required if the abscess is
not safely accessible. At the time of surgery,
definitive repair of the fistula should not be
attempted, because the presence of adjacent
infection precludes healing

53. ■ Patients with fistulas associated with Crohn disease
benefit from anti-inflammatory agents. A short (7- to
10-day) course of cyclosporine has been shown to
decrease fistula output, inflammation, and pain.
■ the fistulas associated with Crohn disease benefit
from anti-inflammatory agents. A short (7- to 10-day)
course of cyclosporine has been shown to decrease
fistula output, inflammation, and pain

54. ■ Infliximab is a chimeric monoclonal antibody to
tumor necrosis factor alpha (TNF-α) that has been
demonstrated to heal as many as 50% of chronic
intestinal fistulas in patients with Crohn disease.
Adverse effects, including headaches, abscess,
upper respiratory tract infection, and fatigue, occur
in more than 60% of patients

55. Surgical Options
■ The procedure involves resection of the intestinal
segment, fistula tract, and the adjacent part of the
involved structure
■ In the absence of extensive infection or
inflammation, primary anastomosis of the divided
intestinal segments is done to reestablish GI
continuity and repair of the involved structure to
maintain function

56. ■ In the presence of extensive infection or
inflammation, the divided intestinal segments are
exteriorized and the surgical procedure modulated to
allow replacement or maximal preservation of
function
■ A staged procedure is performed after the infection
and inflammation subsides to reestablish GI
continuity and carry out reconstruction of the
affected structure

57. Complications
■ Inadvertent enterotomies
■ Excessive blood loss
■ Sepsis
■ Short-bowel syndrome
■ Recurrence of fistulas

58. Thank you