Fistula, Enterocutaneous


Article Author:
Kevin Cowan


Article Editor:
Sebastiano Cassaro


Editors In Chief:
Rhonda Coffman
Lindsay Iverson
Heather Templin


Managing Editors:
Orawan Chaigasame
Carrie Smith
Abdul Waheed
Frank Smeeks
Kristina Soman-Faulkner
Benjamin Eovaldi
Radia Jamil
Sobhan Daneshfar
Pritesh Sheth
Hassam Zulfiqar
Steve Bhimji
John Shell
Matthew Varacallo
Ahmad Malik
Mark Pellegrini
James Hughes
Beata Beatty
Hajira Basit
Phillip Hynes
Kavin Sugumar


Updated:
6/4/2019 6:48:08 PM

Introduction

A fistula is an abnormal connection between two epithelized surfaces. Fistulas can form between any two hollow spaces including blood vessels, intestine, vagina, bladder, and skin. There are three different categories used to define a fistula, anatomic, physiologic, and etiologic. Anatomically, fistulas are subdivided into two categories, internal and external. Internal fistulas are connections between two internal structures. A few examples of an internal fistula would be enterocolic, ileosigmoid, and aortoenteric. Alternatively, external fistulas form connections between an internal structure and external structure. Examples of this would be enterocutaneous, enteroatmospheric, and rectovaginal fistulas. When categorized physiologically, the fistula is differentiated based on fluid output. Low-output fistulas drain less than 200 ml of fluid per day, high-output fistulas drain greater than 500 ml of fluid per day, and medium-output fistulas fall between the two. Etiology is the last way in which fistulas are categorized. Common etiologic categories are traumatic fistulas, surgical site fistulas, and fistulas associated with Crohn's disease. This article will specifically cover fistulas that fall under the anatomical category of enterocutaneous fistulas.[1][2][3][4]

Etiology

It is estimated that 80% of enterocutaneous fistulas are of iatrogenic origin secondary to surgery. Surgical complications, such as enterotomies or intestinal anastomotic dehiscence, are known to be at high risk for the development of an enterocutaneous fistula. Trauma, malignancy, and inflammatory bowel disease increase risk of fistula development postoperatively. The 20% of fistulas not associated with surgery are caused by systemic diseases such as Crohn’s disease, radiation enteritis, malignancies, trauma, or ischemia.[5][6]

Epidemiology

Enterocutaneous fistula mortality rates vary from 6% to 33%.  Incidence is dependent on etiology. Infected pancreatic necrosis has an extremely high incidence of 50%. Trauma patients have a 2% to 25%  incidence, and abdominal sepsis has a 20% to 25% incidence.[7][8][9]

Pathophysiology

The pathophysiology of an enterocutaneous fistula is simple since it is nothing more than an aberrant connection between intestine and skin. Anything that causes a potential communication between the intestine and the epidermis can lead to the development of an enterocutaneous fistula. A constant stream of fluid traveling through this connection will keep the tract patent, and it will provide time for epithelial tissue to migrate into and cover the inner surface of the tract. Epithelialization of the tract will further stabilize the patency of the fistula. These factors contribute to the reasons why short, wide, high output fistulas are more prone to stabilize than long, narrow, low-output fistulas.[10][11]

History and Physical

As previously mentioned, the most common cause of an enterocutaneous fistula is iatrogenic and occurs in the postoperative period. A history of trauma, inflammatory bowel disease, and oncologic surgery places patients at a high risk of developing a fistula.

The following scenario is an example of the events leading up to the development of an enterocutaneous fistula. A patient with a postoperative fever, leukocytosis, ileus, and abdominal tenderness is found to have a wound infection. The next step in treating this patient is to drain the abscess. However, one or two days after draining the abscess, enteric contents are observed in the wound. Finding enteric contents that are continually leaking into the wound establishes a diagnosis of an enterocutaneous fistula.

A helpful, commonly used acronym for remembering the factors that make fistula formation favorable and unlikely to spontaneously regress is “FRIEND.” The acronym is remembered easily with the mnemonic “the friends of the fistula.”

  • F - Foreign body
  • R - Radiation
  • I - Inflammation or infection
  • E - Epithelialization of the fistula tract
  • N - Neoplasm
  • D - Distal obstruction

Evaluation

After stabilizing the patient, the next step is to evaluate the fistula. Ultrasound, CT scan, and fistulography are three imaging modalities that can be used to help characterize a fistula. Small bowel follow-through and endoscopy studies may also be helpful. Imaging is important for determining whether or not all of the fluid traveling through the fistula is coming out of the external opening. In some cases, fluid can be partially leaking into the abdomen and can then lead to the formation of an abscess. CT scan with oral contrast is considered the single best radiologic test since it can identify the tract, abdominal leaking, intra-abdominal abscesses, distal obstruction, and foreign bodies. Fistulography is used less often but can be useful when CT or ultrasound is unavailable or inconclusive. It is performed by injecting contrast into the external opening of the fistula and taking plain film radiographs of the area.

Treatment / Management

The first step in patient management is stabilization. Patients are at a high risk for electrolyte imbalances, sepsis, and malnutrition. Controlling all three of these factors is essential for survival. Electrolyte abnormalities and fluid balance need to be monitored closely because these patients can develop severe derangements quickly. Electrolyte losses vary depending on the location of the fistula in the gastrointestinal (GI) tract and the amount of output. Any deficiencies need to be replaced. In septic patients, a source needs to be identified and appropriately treated. Sepsis is documented as being responsible for two-thirds of mortality in these patients. Intra-abdominal abscesses are common and should be high on the differential as the source of sepsis. The Surviving Sepsis Campaign guidelines should be followed when treating these patients. Most patients will need parenteral nutrition, but a subset of patients may be able to tolerate an enteral elemental diet if the fistula is distal in the GI tract and the output from the fistula is not increased by starting feeds. Either way, adequate nutrition is a well-established, essential component to treat these patients properly. Another important variable to stabilize is the output from the fistula. The fluid needs to be properly contained as not to damage the surrounding skin and to increase odds of healing. Various methods of wound care can aid in preventing skin loss, minimizing pain, and allowing the patient to function on a daily basis. Such strategies are typically similar to ostomy bag appliances, but some will require a more customized plan for containing the fistula output. 

A decision then needs to be made on how to treat the fistula itself. There are some cases in which immediate surgical correction may be appropriate, but the majority of fistulas are treated non-operatively. This is because 90% of fistulas close on their own within 5 weeks of medical management. Depending on the surgeon, 2 to 3 months of will be attempted before the surgical correction of a fistula is considered. This waiting period gives the fistula an appropriate amount of time to close spontaneously. It also decreases the morbidity and mortality of surgical correction. When initiating medical management, the factors mentioned in the previous section that promotes fistula development should be evaluated. All modifiable variables should be corrected to increased chances of spontaneous closure. Low-output fistulas are more likely to close than higher output fistulas. Longer fistula tract length is associated with a higher chance of closing.

The goal of medical management is to decrease fistula output and encourage spontaneous closure. Nasogastric tubes should be avoided. In high output fistulas, proton pump inhibitors (PPIs) and H2 blockers can be used to decrease gastric secretions. Antidiarrheals, such as loperamide, are also effective in reducing the output of high-output fistulas. Octreotide, a somatostatin analog, has been extensively studied for controlling fistula output. It has been shown to decrease output, increase spontaneous closure, and decrease hospital stay, but has never been shown to decrease mortality. If a fistula has over one liter per day of output, an octreotide trial can be attempted. After 72 hours if there is a significant reduction in volume, the medication can be continued.

If the fistula does not resolve with medical management, surgical management will then be considered. Operating on fistulas is fraught with difficulties, and there is a high risk for recurrence. Surgical approach may be difficult due to previous surgeries and adhesions. The bowel must be run carefully, and extreme care must be taken to not cause any accidental enterotomies during lysis of adhesion and bowel mobilization. As long as the bowel looks healthy, the best option is to excise the fistula tract and resect a small amount of associated bowel followed by an anastomosis to reestablish bowel continuity. To decrease recurrence rate, one must make sure to close the fascia where the fistula tract was traversing. As long as medical management, proper nutrition, and an appropriate waiting time precede the operation, permanent resolution of an enterocutaneous fistula occurs in 80% to 95% of cases.

Enhancing Healthcare Team Outcomes

Enterocutaneous fistulas are best managed by a multidisciplinary team that includes a stoma or wound care nurse, dietitian, and therapist. The key is to replace any fluids and electrolytes promptly because these patients can decompensate quickly. The source of sepsis has to be identified. The decision to treat nonsurgically versus surgery requires clinical acumen and good judgment.

The outcomes depend on the cause of the fistula; malignant cases usually have a poor outcome but those in patients with Crohn's disease can take months or years to close.


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Fistula, Enterocutaneous - Questions

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A patient develops an enterocutaneous fistula of the jejunum from Crohn disease. He had surgery twice and the fistula still persists. The amount of fluid draining from the fistula averages about 2.5 liters per day. What replacement fluid, which resembles enteric losses, could be used?



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Which is a false statement about enterocutaneous fistulas?



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Which treatment remedy has been shown to decrease enterocutaneous fistula output?



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Which of the following is a false statement about enterocutaneous fistulas?



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A 55-year-old develops an enterocutaneous fistula originating in the proximal bowel secondary to Crohn disease. Which of the following is the most appropriate replacement for enteric fluids?



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A 70-year-old female had a total abdominal hysterectomy in the distant past and develops a complete small bowel obstruction. She is taken to surgery after conservative treatment fails. Extensive lysis of adhesions was needed and the patient did well until postoperative day 5. She developed fever, tachycardia, and infection of the wound. The incision was opened yielding about 100 mL of purulent material. The wound is packed lightly but the patient continues to be febrile despite antibiotics. 2 days later the drainage from the wound becomes bilious and copious. What is the next step in treatment?



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A 56-year-old male with adenocarcinoma of the colon develops a fever while postoperative day 5 from an open right hemicolectomy with extensive lysis of adhesions and enterotomy repair times 3. The source of the fever is a wound infection. The incision is opened, and an abscess is drained. Three days later the wound dressing is soaked through with enteric contents. What is the next best step in evaluating this patient?



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A 45-year-old female who developed an enterocutaneous fistula during her hospital admission following a complex abdominal surgery presents to the clinic two weeks after fistula development for follow-up. She is tired of having to deal the fistula and say the medical management is not working because it is still there. She is asking for surgical correction as soon as possible. What statement about fistula treatment is true?



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You are called to the emergency department to evaluate a patient on post operative day 12 from a complex abdominal surgery with extensive lysis of adhesions. Several enterotomies were made and had to be repaired. You discover the patient likely has an enterocutaneous fistula. Which of these historical factors are not associated with fistula development?



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A 66-year-old male has recently developed an enterocutaneous fistula. The fistula output is around 1000 ml over a 24 hour period. Which of these treatments should not be used to decrease the output of the fistula?



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What is the number one cause of mortality in patients with an enterocutaneous fistula?



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Fistula, Enterocutaneous - References

References

Ballard DH,Erickson AEM,Ahuja C,Vea R,Sangster GP,D'Agostino HB, Percutaneous management of enterocutaneous fistulae and abscess-fistula complexes. Digestive disease interventions. 2018 Jun;     [PubMed]
Rodrigues-Pinto E,Morais R,Macedo G, Combined over-the-scope clip and detachable snare placement for closure of an enterocutaneous fistula. Endoscopy. 2019 May 9;     [PubMed]
Stevens TW,D'Haens GR,Duijvestein M,Bemelman WA,Buskens CJ,Gecse KB, Diagnostic accuracy of faecal calprotectin in patients with active perianal fistulas. United European gastroenterology journal. 2019 May;     [PubMed]
Li B,Shamah S,Swei E,Chapman CG, Endoscopic closure of a refractory enterocutaneous fistula by use of a fistula plug with fixation and mucosal oversewing. VideoGIE : an official video journal of the American Society for Gastrointestinal Endoscopy. 2019 May;     [PubMed]
Sunday-Adeoye I,Eni UE,Ekwedigwe KC,Isikhuemen ME,Daniyan BC,Yakubu EN,Eliboh MO,Uguru IE, Enterocutaneous Fistula Coexisting with Enterovesical Fistula: A Rare Complication of Ovarian Cystectomy. African journal of reproductive health. 2019 Mar;     [PubMed]
Mosquera-Klinger G,Torres-Rincón R,Jaime-Carvajal J, Endoscopic closure of gastrointestinal perforations and fistulas using the Ovesco Over-The-Scope Clip system at a tertiary hospital center. Revista de gastroenterologia de Mexico. 2019 Apr 20;     [PubMed]
Chang J,Li CC,Achtari M,Stoufi E, Crohn's disease initiated with extraintestinal features. BMJ case reports. 2019 Apr 20;     [PubMed]
Schoepfer A,Santos J,Fournier N,Schibli S,Spalinger J,Vavricka S,Safroneeva E,Aslan N,Rogler G,Braegger C,Nydegger A, Systematic Analysis of the Impact of Diagnostic Delay on Bowel Damage in Paediatric Versus Adult Onset Crohn's Disease. Journal of Crohn's     [PubMed]
Xu X,Ma Y,Yao Z,Zhao Y, Prevalence and Risk Factors for Pressure Ulcers in Patients with Enterocutaneous Fistula: A Retrospective Single-Center Study in China. Medical science monitor : international medical journal of experimental and clinical research. 2019 Apr 9;     [PubMed]
Singh H,Mandavdhare H,Sharma V, All that fistulises is not Crohn's disease: Multiple entero-enteric fistulae in intestinal tuberculosis. Polski przeglad chirurgiczny. 2019 Jan 3;     [PubMed]
Metcalf C, Considerations for the management of enterocutaneous fistula. British journal of nursing (Mark Allen Publishing). 2019 Mar 14;     [PubMed]

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