Intestinal Fistula

1. Intestinal Fistula
By : Dr. Fouad Aldhaheri
Dr. Abdullah Abdulkareem

2. What is fistula ?
• 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. Classification :
• There are various ways by which fistula can be classified :
- Anatomical :
1- external fistula (eg, enterocutaneous fistula or rectovaginal
fistula )
2-internal fistula ( eg , enterocoloic fistula or colovesicular fistula)

4. Classification…Cont
Physiological-based on quantity of daily
output:
• High output->500 ml/day-usually
small bowel; 50% mortality; less chance of
spontaneous closure.
• Moderate output-200-500 ml/day-colonic
and small bowel mixed.
• Lowoutput-<200 ml/day-colonic; mortality
is 15%; more chance of spontaneous closure

5. Classification…Cont
• Acquired fistulas, e.g. entero-cutaneous
fistulas
• Congenital fistulas--tracheo-oesophageal
fistulas.

6. Etiology
• Risk factors for intestinal fistulas include the following:
• 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

7. Etiology… cont
• 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

8. Complication
• 1- Metabolic effects :
a-Dehydration
b-Malnutrition , eg , hypoalbunminaemia
c-Electrolyte disturbances
• 2- sepsis
• 3- skin irritation and maceration

9. Clinical presentation
• Symptoms caused by fistulas that involve two segments of the
bowel vary depending on the location of the fistula such as:
• ileosigmoid fistula may cause diarrhea, weight loss, or abdominal
pain
• gastrocolic fistulas may present with symptoms of abdominal pain,
weight loss, and feculent belching.
• Enterovesical and colovesical present with symptoms of
pneumaturia, fecaluria, and recurrent urinary tract infections

10. Clinical presentation
• External fistulas generally present with symptoms of :
• drainage through the skin
• fever
• prolonged ileus
• abdominal tenderess

11. Investigation
• CBC
• Serum albumin
• Blood urea nitrogen (BUN)
• Creatinine
• Serum electrolyte
• Urine analysis and culture

12. Imaging
• CT. Scanning
• Fistulogram

13. Management of Fistula
• Phase 1
• Resuscitation and restoration of volume with crystalloids
and colloids, blood transfusion to achieve haematocrit of
30%, maintenance of albumin level at 3.0 gm/di with albumin
infusion.
• Sepsis control with antibiotics, percutaneous drainage of
abscess under guidance or open drainage.

14. Management of Fistula … Cont
• Skin care to prevent excoriation using Karya powder, zinc
oxide cream/powder, ionexchange resins, stoma adhesive and
controlled fistula drainage using sump constructed suction
catheter drain system or vacuum assisted closure (VAC)
system or silicone barrier or created inverted cone system.
• Reduction of output of fistula-proton-pump inhibitors,
histamine antagonists, sucralfate, octreotide, infliximab (in
fistula inCrohn's patients). Long-term nasogastricaspiration
should be avoided.

15. Management of Fistula … Cont
• Nutrition: Nutritional status should be assessed by clinical
(weight, anthropometry), biochemical methods. 30 Kcalories/
kg/day; 1.5 g/kg/day of protein is the basic need. Initially
TPN is used. Once patient tolerates oral, enteral feeding
should be started ideally. Enteral feeding (oral/gastrostomy/
jejunostomy) is contraindicated in presence of distal obstruction.
Enteral feeding reduces the sepsis, improves the bowel
activity, caliber, thickness and ability to hold sutures. It also
avoids TPN related problems

16. Management of Fistula … Cont
• Phase 2
• Investigations are done to assess fistula and its causes. It is
done in 7-10 days of fistula formation.
• Fistulogram using water soluble contrast, CT fistulogram
to see the pathological anatomy of fistula-site, number,
length, status of bowel, distal obstruction, presence of
abscess cavity.
• Biochemicalanalysis (electrolytes, haematocrit and albumin)
and renal, hepatic, respiratory, cardiac status should be
assessed carefully

17. Management of Fistula … Cont
• Phase 3
• Decision by observation and assessment, whether fistula
will close spontaneously or not. Favorable fistulas are likely
to close spontaneously but not unfavorable.
• Definitive procedure is done for fistula only after 6 weeks.
Mortality and recurrence is higher if operated prior to 6 weeks
due to obliterative peritonitis

18. Management of Fistula … Cont
• Definitive surgical procedure is lengthy, complex and
team work. Optimum nutrition, proper planning, prophylactic
antibiotics are needed.
• Reopening should be done through a new distant often
transverse incision.

19. Management of Fistula … Cont
• Bowel refunctionalisation by freeing entire bowel from
ligament of Treitz to rectum should be done to clear
adhesions and obstructions and all areas of sepsis and
abscesses. Sharp dissection using scissor should be
done to clear adhesions. As much as possible bowel
injury should be avoided; if occurs it should be closed
transversely using interrupted 3 zero silk sutures.

20. Management of Fistula … Cont
• Resection ofthe boweladjacent to fistula withtrack is the
ideal procedure with end-to-end meticulous two layered
closure using interrupted 3 zero silk sutures.
• When it is not possible, fistula area bypass, Roux-en-Y
drainage, serosal patch technique is used. Duodenal
fistula is better managed by bypass using gastrojejunostomy and
vagotomy without intervening the fistula.

21. Management of Fistula … Cont
• Proper irrigation of abdominal cavity with saline and
antibiotics during procedure, omental flap around the
anastomosis, various solutions to prevent repeat adhesions are
also often done. Supportive jejunostomy may
be added for enteral feeding.
• Abdominal wall closure is important by primary closure
or by using myocutaneous flap. Mesh should not be used
for closure as recurrent fistula may occur.

22. Management of Fistula … Cont
• Phase 4
• Treatment during recovery and healing time also should be
adequate and optimum.
• Supplementing of nutrition, protein, vitamins and essential
element are important.
• Physical, psychological therapy is needed

23. Thank You