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  • • Fever and sepsis

    • Abdominal pain

    • Localized abdominal tenderness

    • External drainage of small bowel contents

    • Dehydration and malnutrition

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Epidemiology

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  • • May form spontaneously as a result of disease (Crohn disease), but > 95% are surgical complications

    • A high-output fistula produces > 500 mL/24 h

    • Most associated with abscesses, which often drain incompletely so that persistent sepsis is a common feature

    • Intestinal fluid escaping through the fistula may excoriate the skin

    • Fluid and electrolyte losses may be severe, especially if it is located in the upper tract or if there is partial or complete distal intestinal obstruction

    • 30% of fistulas close spontaneously

    • -Crohn disease, irradiated bowel, cancer, foreign body, distal obstruction, extensive disruption of intestinal continuity, and a short (< 2 cm) fistula tract are associated with failure of fistulas to heal

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Symptoms and Signs

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  • • Fever

    • Abdominal pain until bowel contents discharge

    • Rapid weight loss

    • Abdominal tenderness

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Laboratory Findings

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  • • Leukocytosis

    • Hemoconcentration

    • Electrolyte abnormalities based on loss through fistula output

    • Metabolic acidosis

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Imaging Findings

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  • • Contrast medium administered orally, per rectum, or through the fistula (fistulogram) delineates the abnormal anatomy (including intrinsic bowel disease) and demonstrates the location and number of fistulas, the length and course of fistula tracts, associated abscess cavities, and the presence of distal obstruction

    CT scan: May identify associated abscesses and allow for percutaneous drainage

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  • • Fluid should be collected from fistula output for measurement of volume and electrolyte composition; subsequent maintenance of homeostasis depends on accurately measuring losses and replacing them

    • In many cases, an incompletely drained abscess can be managed by an interventional radiologist, who passes a catheter through a fistula tract into the associated abscess cavity

    • -Drainage is accomplished, and the fistula may close as the sump tube is gradually withdrawn over a period of weeks.

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Rule Out

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  • • Associated carcinoma

    • Inflammatory bowel disease

    • Anastomotic disruption

    • GI perforation

    • Distal GI obstruction

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  • • GI contrast radiography (upper GI, barium enema, fistulogram)

    • CT scan

    • Serum electrolytes

    • CBC

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When to Admit

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  • • In all acute cases for fluid and electrolyte replacement, delineation of tract, drainage of associated abscesses, and nutrition

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  • • Fluid, electrolyte, and nutritional replacement

    • Protection of skin from excoriation

    • Abscess drainage

    • No enteral intake and NG suction

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Surgery

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  • • The fistulous segment should be resected, associated obstruction relieved, and continuity reestablished by end-to-end anastomosis

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Indications

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  • • Persistence > 1 month

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Contraindications

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  • • The operation should be postponed until intra-abdominal inflammation has resolved—typically 2-3 months after the last operation

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Medications

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  • • H2 receptor antagonists

    • Somatostatin

    • Total parenteral nutrition

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Complications

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