Learning objectives 10.

Make your own algorithm on how to manage this patient,

There is an algorithm in swartz for the management of small bowel obstruction as Figure 28-16 at page 1232, but for this
learning objectives, it was instructed to make our own management for adhesive small bowel obstruction. So for our
algorithm as shown, If there are signs and symptoms of strangulation ( fever, tachycardia or tachynea, localized abdominal
tenderness, leukocytosis) and intestinal ischemia (blood flow to your intestines decreases) then proceed to the operation
room for exploration. If no then, it will be characterized if partial bowel obstruction or complete bowel obstruction. For partial
bowel obstruction. The patient will proceed to NPO, IVF, NGT, Serial abdominal exam. And if the patient develops signs or
symptoms of intestinal ischemia, then proceed to operation room for exploration, and if they are no signs or symptoms of
intestinal ischemia, continue conservative management duration dependent on etiology and surgeon choice. For complete
bowel obstruction, the patient will have NPO, IVF, NGT, and serial abdominal exam, and if the patient develops signs or
symptoms of intestinal ischemia then proceed to operating room for exploration. And if no symptoms of intestinal ischemia,
improving after 24 hours of conservative management, then continue management, and no improvement proceed to
operating room for exploration.

That would be all doc,

So for case 2,

SGD Day 2: CASE 2

A 40-year-old male was admitted in the hospital 20 days post-op after developing a partial small bowel obstruction
secondary to multiple abdominal incisional hernias that required repair; recovery was complicated by the
development of multiple intraabdominal abscesses. His history was significant for a motor vehicle crash dating back
to 2002 where he sustained multiple orthopedic and intra-abdominal injuries that required numerous surgical
interventions. Before transfer to our facility, he underwent lysis of adhesions, repair of multiple hernias and
resection of a loop of small bowel (ileum) with a primary anastomosis after a bowel perforation.

Currently he presented in the ER with a deep wound infection at the inferior pole of the laparotomy site. He has
stable vital signs but show signs of dehydration. Bilious succus fluid was noted to drain from the wound. Daily
wound drainage was estimated to range from 250-330 cc for the past 4 days.

Next slide doc,

For learning objective number 1,

What is ECF? How do we classify ecf?

Next slide doc please,

According to swartzs, A fistula is defined as an abnormal communication between two epithelialized surfaces. The
communication occurs between two parts of the gastrointestinal tract or adjacent organs in an internal fistula or Gi tract with
the skin (An external fistula).

Moreover, Internal fistula- occurs between two parts of the gastrointestinal tract or adjacent organs. And examples of internal
fistulas are enterocolonic fistula or colovesicular fistula. An external fistula involves the skin or another external surface
epithelium. And enterocutaneous fistula or rectovaginal fistula for its examples.

Next slide please,

Types of enterocutaneous fistulas it is based on the volume of output

 ▪ Enterocutaneous fistulas that drain less than 200 mL of fluid per day are known as low-output
fistulas, Low-output fistulas are treated medically. To Lessen passage of fluid → Give TPN,
low-residue diet for colocutaneous fistula and elemental diet for enterocutaneous fistula

((limits dietary fibre to less than 10-15g per day and restricts other foods that
could stimulate bowel activity. The goal of a LRD is to decrease the size and
frequency of bowel movements in order to reduce painful symptoms.))

((The elemental diet is a liquid meal replacement diet that offers a

complete nutritional profile broken down into its most “elemental”
form. Proteins, fats and carbohydrates are broken down into amino
acids, short-chain triglycerides and short-chain maltodextrins,
combined with vitamins, minerals and electrolytes. These dietary
“building blocks” are easily absorbed in the upper digestive tract,
allowing the rest of your digestive system to rest and recover from illness
or injury. They come in a liquid or powder form designed to be mixed
with water. They can be taken orally or enterally (through a tube).))

▪ Moderate output fistula- those that drains between 200 and 500 mL per day

o And high-output fistulas those that drain more than 500 mL of fluid per day. High-output fistulas are
treated surgically unless you can convert it to a low-output fistula. To decrease output give octreotide
or somastostatin.

((MOA Somatostatin and Octreotide- The proposed mechanisms of action include a reduction in splanchnic and
gastroduodenal mucosal blood flow, a decrease in GI motility, inhibition of gastric acid secretion, inhibition of
pepsin secretion, and gastric mucosal cytoprotective effects.)

((A subcutaneous injection is a method of administering medication. Subcutaneous means under the skin. In
this type of injection, a short needle is used to inject a drug into the tissue layer between the skin and the
muscle.))

So for our case, the patient has an estimation of 250-330 cc or mL daily wound drainage for the past 4 days he has
a moderate output fistula.
A fistula is an abnormal communication between two epithelialized surfaces; an
enterocutaneous fistula (ECF), as the name indicates, is an abnormal communication
between the small or large bowel and the skin. An ECF can arise from the duodenum,
jejunum, ileum, colon, or rectum. (See the image below.)

Almost healed wound around an

enterocutaneous fistula.
View Media Gallery
Although fistulas arising from other regions of the gastrointestinal (GI) tract (eg, stomach and
esophagus) may sometimes be included in the definition of ECF, the discussion in this article
is limited to the conventional definition of this condition. A fistula-in-ano, though anatomically
an ECF, conventionally is not referred to as such, because its presentation and management
are different.
An ECF, which is classified as an external fistula (as opposed to an internal fistula, which is
an abnormal communication between two hollow viscera), is a complication that is usually
seen after surgery on the small or large bowel. In one study, about 95% of ECFs were
postoperative, and the ileum was the most common site of ECF [1] ; 49% of fistulas were
high-output, and 51% were low-output.
ECFs are a common presentation in general surgical wards, and despite advances in the
management of these lesions, they are still responsible for a significant mortality (5-20%),
attributable to associated sepsis, nutritional abnormalities, and electrolyte imbalances.
Understanding the pathophysiology of, as well as the risk factors for, ECFs should help to
reduce their occurrence. Moreover, the well-established treatment guidelines for these
lesions, along with some newer treatment options, should help clinicians achieve better
outcomes in patients with an ECF.
The conventional therapy for an ECF in the initial phase is always conservative.
(See Treatment.) Immediate surgical therapy on presentation is contraindicated; however,
patients who have an ECF with adverse factors may require early surgical intervention.
Treatment of ECFs continues to be a difficult task.
In a landmark article, Edmunds et al provided a comprehensive discussion of ECF. [2] Of 157
patients in the study, 67 developed ECF following surgery. Important complications of ECF
included fluid and electrolyte imbalance, malnutrition, and generalized peritonitis. Mortality
was 62% in patients with gastric and duodenal fistulas, 54% in patients with small-bowel
fistulas, and 16% with colonic fistulas.
Etiology
An ECF can occur as a complication following any type of surgery on the GI tract. Indeed,
more than 75% of all ECFs arise as a postoperative complication, whereas about 15-25%
result from abdominal trauma or occur spontaneously in relation to cancer,
irradiation, inflammatory bowel disease (IBD), or ischemic or infective conditions. The
etiology of ECFs can thus be characterized as postoperative, traumatic, or spontaneous.
Postoperative
Postoperative causes of ECFs include the following:
• Disruption of anastomosis
• Inadvertent enterotomy - Occurs especially in patients with adhesions, when
dissection can cause multiple serosal tears and an occasional full-thickness tear
• Inadvertent small-bowel injury - Occurs during abdominal closure, especially after
ventral hernia repair
Disruption of anastomosis can result from inadequate blood flow due to an improper vascular
supply, especially when extensive mesenteric vessels have to be ligated. Tension on
anastomotic lines following colonic resection, restoration of continuity without adequate
mobilization, or a minimal leak or infection can lead to perianastomotic abscess formation,
resulting in disruption, as seen in patients with anterior resection for rectal carcinoma. In
addition, if anastomosis is performed in an unhealthy (eg, diseased or ischemic) bowel, it can
lead to disruption and cause an ECF.
Inadvertent picking up of the bowel during abdominal closure can result in a small-bowel
fistula; this especially can occur with the use of open inlay mesh or intraperitoneal onlay
mesh repair by the laparoscopic method, when the viscera comes in contact with the mesh,
leading to adhesions and sometimes to disruption.
Gastroduodenal fistulas are seen most often after surgery for perforated peptic ulcer,
especially in developing countries, where perforated peptic ulcer is more common. In
patients with a perforated duodenal ulcer, when the perforation is large, extensive
contamination is present. When the duration between perforation and surgery is long, there
is a high possibility of a postoperative leak, leading to a lateral duodenal fistula. This problem
is difficult to treat, and mortality is high. Other causes of gastroduodenal leakage include
surgery for stomach and the biliary tract cancers.
A colocutaneous fistula can develop after colonic surgery, especially when the blood supply
to a low colorectal/anal anastomosis is compromised or when there is tension at the
anastomotic suture line. This type of fistula can also result from diseases of the colon, such
as IBD or malignancy leading to perforation, pericolic abscess formation, and ECF.
Surgery for appendicitis, appendicular perforation at the base, or drainage of an
appendicular abscess can also lead to a colocutaneous fistula. Radiation therapy is also
another major cause of colonic fistula. [3] In rare cases, migration of a polypropylene or
composite mesh from a hernia repair can lead to ECF formation. [4, 5]
Hew et al reported a rare case of ECF following migration of a hepatic artery infusion
catheter in a patient with colorectal liver metastasis. [6]
Traumatic
Traumatic ECF results from iatrogenic surgical trauma to the bowel that may or may not be
recognized. Road traffic accidents with injury to the gut can also lead to an ECF. [7]
Spontaneous
Spontaneous causes of ECF, seen in about 15-25% of cases, include the following:
• Malignancy
• Radiation enteritis with perforation
• Intra-abdominal sepsis
• IBD (eg, Crohn disease [3] )
Ulcerative colitis (UC) can also lead to spontaneous ECF, but most cases of ECF associated
with this IBD occur as a postoperative complication of restorative proctocolectomy. [8] Rarely,
inadvertent incision of a malignant tumor can lead to an ECF (see the image below). In this
patient, a urachal tumor was inadvertently incised when the patient underwent an
appendectomy by midline incision. The patient presented with ECF (colocutaneous fistula)
as the urachal tumor that ulcerated on the abdominal wall postoperatively had also infiltrated
the sigmoid colon.

Postoperative malignant enterocutaneous

fistula.
View Media Gallery
A duodenal fistula can occur in association with a perforated duodenal ulcer, but again, it
most often arises postoperatively, resulting from a leak.
Prognosis
ECF is a common condition in most general surgical wards. Mortality has fallen significantly
since the late 1980s, from as high as 40-65% to as low as 5-20%, largely as a result of
advances in intensive care, nutritional support, antimicrobial therapy, wound care, and
operative techniques. [9, 10] Even so, the mortality is still high, in the range of 30-35%, in
patients with high-output ECFs.
Once a patient develops an ECF, the morbidity associated with the surgical procedure or the
primary disease increases, affecting the patient's quality of life, lengthening the hospital stay,
and raising the overall treatment cost. Malnutrition, sepsis, and fluid electrolyte imbalance
are the primary causes of mortality in patients with an ECF.
Another factor that may be a predictor for poor healing outcomes is psoas muscle density,
which can reflect sarcopenia. [11] Assessment of psoas muscle density can identify patients
with ECF who will have poorer outcomes, and these patients may benefit from additional
interventions and recovery time before operative repair.
If sepsis is not controlled, progressive deterioration occurs, and patients succumb to
septicemia. Other sepsis-related complications include intra-abdominal abscess, soft-tissue
infection, and generalized peritonitis. [12]
However, patients with an ECF with favorable factors for spontaneous closure have a good
prognosis and a lower mortality.
Favorable factors for spontaneous closure
Spontaneous closure of an ECF is determined by certain anatomic factors. Fistulas that have
a good chance of healing include the following:
• End fistulas (eg, those arising from leakage through a duodenal stump after Pólya
gastrectomy)
• Jejunal fistulas
• Colonic fistulas
• Continuity-maintained fistulas - These allow the patient to pass stool
• Small-defect fistulas
• Long-tract fistulas
In addition, a fistulous tract of more than 2 cm has a higher possibility of spontaneous
closure. Spontaneous closure is also possible if the bowel-wall disruption is partial and other
factors are favorable. If the disruption is complete, surgical intervention is necessary to
restore intestinal continuity.
Unfavorable factors for spontaneous closure
When an ECF is associated with adverse factors, then spontaneous closure does not
commonly occur, and surgical intervention, despite its associated risks, is frequently
required. In these patients, the outcome is less likely to be good. [13]
Factors preventing the spontaneous closure of an ECF can be remembered by using the
acronym FRIEND, which represents the following [14] :
• Foreign body
• Radiation
• Inflammation/infection/IBD
• Epithelialization of the fistula tract
• Neoplasm
• Distal obstruction - A distal obstruction prevents the spontaneous closure of an
ECF, even in the presence of other favorable factors; if present, surgical
intervention is needed to relieve the obstruction
In addition, lateral duodenal, ligament of Treitz, and ileal fistulas have less tendency to
spontaneously close. [12]
Excoriation
Skin excoriation (see the image below) is one of the complications that can lead to significant
morbidity in patients with ECF. When the enteric contents are more fluid than solid, this
becomes a difficult problem; the skin excoriation makes it difficult to put a collecting bag or
dressings over the fistula, and more leakage leads to an increase in the excoriation.
 Enterocutaneous fistula with severe skin
excoriation.

History and Physical Examination

Features suggestive of an enterocutaneous fistula (ECF) include postoperative abdominal
pain, tenderness, distention, enteric contents from the drain site, and the main abdominal
wound. Tachycardia and pyrexia may also be present, as may signs of localized or diffuse
peritonitis, including guarding, rigidity, and rebound tenderness.
The type of ECF, as based on the output of the enteric contents, also determines the
patient's health status and how the patient may respond to therapy. ECFs are usually
classified into three categories, as follows [3] :
• Low-output fistula (< 200 mL/day),
• Moderate-output fistula (200-500 mL/day)
• High-output fistula (>500 mL/day)
Complications
Patients with ECF present with associated complications, such as sepsis, fluid and
electrolyte abnormalities, and malnutrition.
The degree of sepsis depends on the state of the ECF. If the fistula forms a direct tract
through which the bowel contents are draining onto the skin, then the sepsis may be
minimal, whereas if the fistula forms an indirect tract through which the bowel contents are
draining into an abscess cavity and then onto the skin, the degree of sepsis may be higher.
In the presence of extensive peritoneal contamination or generalized peritonitis with ECF,
the patient can be toxic as a consequence of severe sepsis.
Leakage of protein-rich enteric contents, intra-abdominal sepsis, or electrolyte imbalance–
related paralytic ileus, as well as a general feeling of ill health, leads to reduced nutritional
intake by these patients, resulting in malnutrition. Nearly 70% of patients with ECFs may
have malnutrition, and it is a significant prognostic factor for spontaneous fistula closure. [15]
Sepsis, malnutrition, and electrolyte imbalance are the predominant factors that lead to
death in patients with ECF. [16] Rarely, intestinal failure can occur as one of the complications
of ECF, which results in significant morbidity and mortality. [17]
A high-output fistula increases the possibility of fluid and electrolyte imbalance and
malnutrition.

Laboratory Studies
The following laboratory studies are performed in the evaluation of an enterocutaneous
fistula (ECF):
 • Total white blood cell (WBC) count - This is important because sepsis can lead to
leukocytosis
• Serum sodium, potassium, and chloride levels - Electrolyte abnormalities can
result from fluid and electrolyte loss
• Complete blood count (CBC), total proteins, serum albumin, and globulin - These
can demonstrate the presence of malnutrition-associated
anemia/hypoalbuminemia
• Serum transferrin - Low levels (< 200 mg/dL) are a predictor of poor healing
• Serum C-reactive protein (CRP) - Levels may be elevated
Imaging Studies
Fistulography
During fistulography (see the images below), a water-soluble contrast agent is injected into
the fistulous tract.

Fistulogram showing enterocutaneous fistula.

View Media Gallery
 Fistulogram showing a colocutaneous fistula
following anastomotic leak after colostomy closure.
View Media Gallery
Fistulography is conventionally performed 7-10 days after the presentation of an ECF and
provides the following information:
• Length of the tract
• Extent of the bowel-wall disruption
• Location of the fistula
• Presence of a distal obstruction

Water-soluble contrast enema

The different types of tracts that can be seen by using a water-soluble contrast enema
(WCE) in patients with ECF with failure of low colorectal anastomosis may be classified as
follows [18] :
• I – Simple, short blind ending, < 2 cm
• II - Continuous linear, long single, >2 cm
• III - Continuous complex, multiple linear
Tract positions are as follows:
• Anterior - Ventral (10-o’clock to 2-o’clock position)
• Posterior - Dorsal (4-o’clock to 8-o’clock position)
• Lateral - Right (2-o’clock to 4-o’clock position) or left (8-o’clock to 10-o’clock
position)
Additional tract features seen with a WCE include a cavity (pooling of contrast within space),
a stricture (narrowing of anastomosis, with hold of contrast), or both. The presence of a
stricture and a large cavity on WCE predicts failure of healing.
Computed tomography
Computed tomography (CT) is useful for demonstrating intra-abdominal abscess cavities.
Such cavities can develop if an ECF has an indirect tract when it first drains into an abscess
cavity and then drains to the exterior cavity. If an ECF is associated with intra-abdominal
sepsis, then interloop abscesses may be present.
Ultrasonography
A comprehensive ultrasound examination has been employed for the evaluation of
postoperative complications after hernia repair. Whereas point-of-care ultrasound (POCUS)
has been commonly used for abscess evaluation, it can also be an alternative in an
emergency presentation of an ECF. [19]
Other Tests
Oral administration of a nonabsorbable marker (eg, charcoal or Congo red) can help confirm
the presence of an ECF.

Methylene blue diluted in saline can be administered through a nasogastric tube as a simple
bedside test to confirm the presence of an ECF, especially in patients with a
gastrocutaneous or lateral duodenal fistula. This test can also help to determine whether the
leak is from a segment that is in the continuity of the gastrointestinal tract, especially in the
case of proximal fistulas. However, because methylene blue loses diagnostic efficacy as it
becomes diluted with intestinal secretions, its role in identifying distal ECFs is limited.

Approach Considerations
The conventional therapy for an enterocutaneous fistula (ECF) in the initial phase is always
conservative. Immediate surgical therapy on presentation is contraindicated, because the
majority of ECFs spontaneously close as a result of conservative therapy. Surgical
intervention in the presence of sepsis and poor general condition would be hazardous for the
patient.
However, patients who have an ECF with adverse factors, such as a lateral duodenal fistula,
an ileal fistula, a high-output fistula, or a fistula associated with a diseased bowel, may
require early surgical intervention.
Zhou et al described a novel technique of using the orchid Bletilla striata in the closure of
ECF. [20] In a case of ECF following colonic neoplasm resection managed conservatively,
application of B striata led to spontaneous closure of the fistula. This plant was found to
suppress inflammation and promote wound healing.
Conservative Therapy
Conservative treatment should usually be administered for a period ranging from a few
weeks to a few months. The principles of nonsurgical therapy for ECFs include the following:
• Rehydration
• Administration of antibiotics
• Correction of anemia
• Electrolyte repletion
• Drainage of obvious abscess
• Nutritional support
• Control of fistula drainage
• Skin protection
With the above-mentioned supportive therapy, spontaneous closure occurs in almost 70% of
patients. In a study of 186 patients, Reber et al found that 91% of small-bowel fistulas that
closed spontaneously did so within 1 month after sepsis was cured. The remaining fistulas
that closed spontaneously did so by the end of 3 months after sepsis cure, with the rest of
the lesions requiring surgical closure. [21]
Uba et al reported that the majority of ECFs in children closed spontaneously following high-
protein and high-carbohydrate nutrition. [22] They found that hypoalbuminemia and jejunal
location were important variables resulting in nonspontaneous closure, whereas
hypokalemia, sepsis, and hypoproteinemia/hypoalbuminemia were risk factors for high
mortality in children with ECF.
Rehydration, electrolyte repletion, and nutritional support
Common fluid and electrolyte problems that must be corrected in patients with an ECF
include the following:
• Dehydration
• Hyponatremia
• Hypokalemia
• Metabolic acidosis
The author uses parenteral nutrition more often in patients with a proximal small-bowel ECF,
especially if it is in the proximal jejunum, or with a high-output fistula. In patients with a distal
ECF, the author prefers to use enteral nutrition whenever possible.
Studies have shown that the provision of only 20% of calories fed enterally may protect the
integrity of the mucosal barrier, as well as the immunologic and hormonal function of the
gut. [12] Hence, a combination of parenteral and enteral nutrition can be used. In high-output
fistulas, the author uses this combination therapy.
In patients with a proximal fistula, if a nasojejunal tube can be introduced beyond the site of
the fistula, then these patients can be supported with enteral nutrition, provided that there is
at least 4-5 ft (1.2-1.5 m) of small bowel distal to it and no distal obstruction. Patients with
chronic small-bowel ECFs may need additional supplementation with copper, folic acid, and
vitamin B12. [12]
Total parenteral nutrition
Total parenteral nutrition (TPN) is usually indicated with suspected gastric, duodenal, or
small-bowel fistula. When the fistula output is very high, discontinuance of oral intake is
recommended because oral intake stimulates further losses of fluids, electrolytes, and
protein via the fistula. A decrease in fistula output frequently occurs with the initiation of TPN.
Home parenteral nutrition (HPN) is a vital therapy for patients who have the diagnosis of
ECF, and it has reported to be successful for patients with ECF as compared with other HPN
patients. [23] Greater provision of protein, more frequent NPO (nil per os) status, and a goal of
future surgery should be the focus in ECF patients on HPN.
Water requirements for TPN are 1 mL/kcal/day. Electrolyte requirements for TPN are as
follows:
• Sodium (Na) - 80-100 mEq/day
• Potassium (K) - 75-100 mEq/day
• Magnesium (Mg) - 15-20 mEq/day
• Calcium (Ca) - 15-20 mEq/day
Calorie and protein requirements are as follows:
• Maintenance – 25-30 kcal, 1.0-1.2 g/kg/day
• Moderate stress – 30-40 kcal, 1.3-1.4 g/kg/day
• Severe stress – 40-45 kcal, 1.5-2.0 g/kg/day
Protein (g)/6.25 should equal nitrogen (g), and the nonprotein calorie-to-nitrogen ratio should
be as follows:
• Maintenance - 200-300:1
 • Moderate stress - 150:1
• Severe stress - < 100:1
A standard, general-purpose formula for TPN consists of the following:
• Glucose, 75 g
• Amino acids, 20 g
• Lipids, 30 g/L
The introduction of ethyl vinyl acetate bags has made the admixture of fat emulsion with
dextrose and amino acids possible (three-in-one concept). [24] This leads to a more uniform
administration of a balanced solution containing the three macronutrients plus micronutrients
over a 24-hour period.
Enteral nutrition
Enteral nutrition is the mainstay of treatment for patients with ECFs. In fistulas of the distal
ileum, colon, or duodenum, enteral nutrition should be considered and can be administered
via various routes. Conventionally, when a gastroduodenal anastomosis or closure is needed
in adverse conditions, a concomitant feeding jejunostomy is performed, so that access is
available for enteral nutritional support in case of an anastomotic leak.
The other routes of administration can be via nasogastric/jejunal tubes or a gastrostomy.
High rates of feeding should be avoided to prevent hyperosmolar diarrhea. Elemental diets,
that is, nonresidue balanced diets with protein components reduced to their basic elements,
are preferred. When a tube enterostomy is performed, proper fixation is necessary to prevent
complications, such as dislodgment of the tube or antegrade migration in the gastrointestinal
(GI) tract. [25]
Martinez et al reported a prospective randomized trial on the effect of preoperative
administration of oral arginine and glutamine in 40 patients with ECF undergoing definitive
surgery, of whom 20 received standard medical care (control group) and 20 received enteral
supplementation with arginine 4.5 g/day and glutamine 10 g/day for 7 days prior to surgery
(test group). [26] The primary outcome was recurrence; secondary outcomes were pre- and
postoperative serum interleukin (IL)-6 and C-reactive protein (CRP) levels and infectious
complications. The recurrence rate was 10% in the test group and 45% in the control group.
The test group had lower IL-6 and CRP levels and no infectious complications.
Fistuloclysis
Enteral nutrition can also be administered in patients with high-output proximal
jejunocutaneous or ileocutaneous fistulas with good mucocutaneous continuity. Feeding can
be administered through a feeding tube inserted in the distal limb of the ECF. Teubner et al
and Ham et al reported good results with this method in select patients to improve the
nutrition of the patient, which is helpful for subsequent fistula closure and promotes healing
of the fistula. [27, 28, 29] An interprofessional approach is needed. [30]
Skin management
Irrgang et al developed a fistula assessment guide that has aided skin management related
to ECFs. [31] This guide is based on the following characteristics:
• Origin of fistula
• Nature of effluent
• Condition of skin
• Location of fistula opening
For a high-output fistula, a pouch system is preferable to a conventional skin dressing. For a
low-output fistula, a skin barrier with a dressing or pouch is advocated.
The degree of skin irritation present (from erythema to maceration to skin loss) guides the
type of skin-protecting agents that should be applied and the type of pouch system that
should be used. In addition, an important consideration is whether the opening is flush with
the skin, retracted and deep, close to bony prominences, or in an open wound.
Pouches used for skin care
When the fistula output is high, it is desirable to use a pouch for collecting the enteric
effluents. Ostomy pouches in one- or two-piece designs with either a drainable clip or a
urostomy-type closure can be cut and fit to perifistular skin. If the area of the fistula is on an
irregular body contour (eg, close to bony prominences), then a one-piece pouch is more
suitable because it can adhere better.
A transparent pouch is preferred to an opaque pouch, for visualization of the fistula. A pouch
with a skin-barrier backing is more durable than one with an adhesive backing. Wound
manager bags (see the image below) are preferable in that they are specifically designed to
help make wound care easier with good skin protection and access to the wound for its care.

Wound manager.
View Media Gallery
Skin barriers
Powder, paste, wafers, spray, and creams are used as skin barriers for the protection of skin
from the enteric effluents.
Pectin-based wafers that melt and seal with the skin provide a good barrier and offer
protection for a variable period before the skin breaks down and ulcerates. In low-output
fistulas, absorbent dressings can be put on top of the skin-barrier wafer to absorb any
effluent overflow. The skin wafer protects the adjoining skin from erythema and maceration.
Pectin- or karaya-based powders and paste are used. Powders are preferred over a paste in
wet, weepy, perifistular skin when severe skin maceration is present. A generous amount of
powder should be used and continuously added for good results. In patients with weepy skin
and a high-output fistula, management becomes difficult.
A spray provides a protective film and is helpful for pouching, but it might not be beneficial if
used alone.
Zinc creams (see the images below) are used to waterproof and protect the skin. Again, a
generous amount with continuous replacement is necessary because the cream is washed
away with discharging enteric effluents.

Zinc oxide cream for skin protection.

View Media Gallery

Zinc oxide cream barrier around

enterocutaneous fistula, with the fistula opening seen.
View Media Gallery
Control of fistula drainage
The fistula tract is intubated with a drain (see the image below). Volume depletion from a
proximal high-output fistula can be controlled with the use of the long-acting somatostatin
analogue octreotide, which acts by inhibiting GI hormones. The administration of octreotide
reportedly diminishes fistula output, but whether it shortens the time required for fistula
closure remains to be determined. [32]
 Intubation of fistulous tract with drain.
View Media Gallery
Draus et al recommended a 3-day trial of octreotide, maintaining that if the fistula output is
reduced during this time, then administration of the drug should be continued. [33] (Octreotide
use is associated with an increased incidence of cholelithiasis. [12] ) Two meta-analyses
showed that somatostatin and its analogues decreased the time for fistula closure and
increased the closure rate. [34, 35] However, there was no significant change in the mortality
with the use of somatostatin or its analogues.
A study on management of high-output ECF with continuous triple-cavity tube drainage in
combination with sequential somatostatin-somatotropin administration was reported in three
patients with three different forms of ECF (duodenal, jejunal and ileal) and three different
approaches to drainage tube (through the initial drainage channel, puncture with dilatation,
and tract reconstruction, respectively). [36] This measure was carried out with the aims of
creating a stable controlled fistulous tract and promoting its healing. It was found to be safe
and effective, especially when surgery was contraindicated.
Hyon et al reported on a vacuum-sealing method to reduce output, in which a
semipermeable barrier was created over the fistula by vacuum packing a synthetic,
hydrophobic polymer covered with a self-adherent surgical sheet. To set up the system, the
investigators built a vacuum chamber equipped with precision instruments; the chamber
supplied subatmospheric pressures of 350-450 mm Hg. The pressure reduced the daily
fistula output from 800 mL to about 10 mL, thus restoring bowel transit and physiology. [37]
Draus et al reported that the use of a vacuum-assisted closure (VAC) system for wounds,
which consisted of an evacuation tube embedded in a polyurethane foam dressing, helped
improve the condition of the wound, prevented skin excoriation, and promoted wound
contracture and healing. [33] Administration of agents that decrease intestinal pressure may
enhance the efficacy of VAC. [38]
Oliva et al described a nonoperative technique involving the insertion of an occlusive device
to redirect the intestinal content to the distal bowel in patients with lateral high-output
ECF. [39] This was a transient procedure aimed at reducing the fistula output.
Electrical nerve stimulation
Electrical nerve stimulation (ENS) increases blood flow in ischemic tissues and encourages
healing. Berna et al reported the successful use of ENS in two patients with a low-output
ECF. In the study, the direction and depth of the fistula tract were ultrasonographically
determined. A sterile compress impregnated with saline solution was then introduced
through the fistula. The positive electrode was positioned on the compress, and the negative
electrode was positioned over the fistula orifice. [40]
The treatment was given once daily for 1 hour, with one patient requiring 10 treatment
sessions to heal and the second patient requiring 20 sessions. ENS was well tolerated by
both patients, and no complications were noted. No recurrence of the fistula developed over
a 3-year follow-up period.
Laser ablation for chronic ECF after failed conservative therapy
Laser ablation has been used for the treatment of chronic ECFs after failure of conservative
therapy. In a study by Srinivasa et al, three patients underwent laser ablation for treatment of
eight ECFs (mean duration of ECF, 28 months; mean fistula output, 134 mL/day). [41] Initially,
all of the ECFs responsed completely to laser ablation, with no major or minor complications;
however, later three ECFs subsequently required repeat treatment. Overall, at a mean
follow-up of 53 days, seven fistulas healed, and one showed a markedly reduced output (10
mL/day).
Andrés Moreno et al reported the successful use of combination therapy with a laser diode
followed by embolization of the tract with platinum coils and cyanoacrylate to close an ECF
after multiple surgical procedures. [42]
Surgical Therapy
Indications for surgery
Patients who an ECF with adverse factors may require earlier surgical intervention. These
adverse factors include the following:
• Lateral duodenal or ligament of Treitz fistula
• Ileal fistula
• High-output fistula
• Fistula associated with diseased bowel, distal obstruction, or eversion of mucosa
(see the image below)
 Eversion of mucosa in an enterocutaneous
fistula, an unfavorable condition for spontaneous closure.
View Media Gallery
Enteroatmospheric fistula (EAF), a special subset of ECF, is defined as a communication
between the GI tract and the atmosphere. [43] It can occur as a complication of "damage
control" laparotomy (DCL) and results in significant morbidity and mortality. The etiology is
complex and ranges from persistent abdominal infection, anastomotic dehiscence, and
adhesions of the bowel to fascia with a laparostoma. Multiple fistulas and preoperative CRP
levels higher than 0.5 mg/dL have been reported to be associated with recurrence after
closure of EAF. [44]
Because EAFs almost never close spontaneously, definitive repair usually requires major
surgical intervention. Complex abdominal-wall reconstruction immediately after fistula
resection is necessary for all EAFs once the infection has subsided, which may be 6-12
months after the original insult. [45] A “fistula patch” technique has also been reported for
protecting open abdominal wounds from being contaminated by intestinal fistulae drainage,
while and simultaneously applying enteral nutrition. [46]
Because the possibility of spontaneous closure is reduced in patients with adverse factors,
surgical intervention should be undertaken after a 4- to 6-week trial of conservative therapy,
if no signs of spontaneous closure exist. Surgical procedures in patients with adverse factors
can include draining an abscess, creating stomas by exteriorizing the bowel, or creating
controlled fistulas. When feasible, resection of the fistula with restoration of GI continuity is
performed.
In patients with no associated adverse factors, the author usually waits for about 3-4 months
before planning surgical therapy for an ECF.
Surgical therapy [47] should be undertaken in patients with conventional fistulas without any
adverse factors if the patient is stable, has no sources of sepsis, and can withstand the
resectional procedure needed for fistula closure. [12] It is also important that it be technically
feasible to perform the procedure without posing a very high risk of injury to the bowel or
other important structures. Patients with an almost completely healed wound with a fistulous
opening (shown below) have a good chance of responding to surgical therapy.
 Almost healed wound around an
enterocutaneous fistula.
View Media Gallery

Fistula tract being excised.

View Media Gallery
Operative details
In addition to ensuring that patients are stable and free from sources of sepsis before
surgical correction of an ECF is undertaken, antibiotic prophylaxis should be performed and
parenteral nutritional supplementation provided as necessary during the preoperative and
the perioperative periods to achieve good results. Enteral feeding should be decreased to
allow luminal antibiotic preparation. Antibiotic therapy should be administered after the
culture sensitivity of earlier-grown organisms has been checked. [12]
Incision
When performing surgery for an ECF, the author makes a point of always entering the
abdomen through a fresh incision, given the possibility that the gut may be adherent to the
site of the incision of the index operation. If the native incision follows a supraumbilical
midline route, then the author takes an infraumbilical midline route and then extends it to the
operative site.
If it is in the middle portion of the midline, then the author makes either an incision in the
midline superior or inferior to the native incision or a transverse incision to approach the
abdomen. The author always enters the peritoneal cavity in a relatively virgin area to lessen
the chance of an inadvertent enterotomy.
Excision and restoration of bowel continuity
Once an assessment is made in the peritoneal cavity, then the entire bowel from the
ligament of Treitz to the rectum is made free of all adhesions. Once this is achieved, the
fistulous site is dissected free from the surrounding structures, and a complete excision is
done. The author prefers to restore bowel continuity by using a two-layer anastomosis,
employing interrupted nonabsorbable suture of healthy and well-vascularized bowel. The
author uses this approach for small-bowel as well as large-bowel anastomosis.
An inner layer consisting of continuous absorbable suture and an outer layer consisting of
interrupted nonabsorbable sutures can also be used to restore bowel continuity. Other
alternatives include the use of staplers, especially in low colorectal anastomoses.
Treatment of abscess or diseased bowel
If an abscess or diseased bowel segments are seen, then drainage of the abscess or
resection of the diseased bowel is performed. [10] If the patient is too sick to tolerate a
resectional procedure, then exteriorization of the bowel via ileostomy or colostomy is carried
out.
Roux-en-Y drainages or a serosal patch can sometimes be used, especially for a lateral
duodenal fistula following a leak after simple closure of a perforated duodenal
ulcer. [12] However, the results of these procedures are not very encouraging. Converting a
lateral duodenal fistula into an end fistula with a tube duodenostomy is a good option but
may not be possible in most patients.
If anastomosis is performed close to a duodenojejunal flexure, then adequate
decompression by gastrostomy and feeding jejunostomy are carried out. The latter is also
performed when proximal fistula repair is undertaken (eg, lateral duodenal fistula).
Myocutaneous or fasciocutaneous flap
De Weerd et al described the use of a sandwich-design myocutaneous flap cover to close a
high-output ECF. [48] In the initial phase of treatment, the authors used a VAC system for
wound care to promote the development of granulation tissue around the fistulous opening.
The fistula was then closed with serratus muscle from a composite free latissimus dorsi–
serratus flap. The large abdominal wall defect was closed with the musculocutaneous
latissimus dorsi flap taken from the composite flap. The placement of a VAC system between
the serratus and the latissimus dorsi helped to fix the serratus to the fistula.
Successful direct repair of an ECF using a surrounding fasciocutaneous flap has also been
reported. [49]
Postoperative Care
In the postoperative phase of surgical therapy for an ECF, good nutritional status is essential
because healing of the tissue and anastomosis depends on it.
Antibiotic coverage is needed if the operation is performed in the presence of sepsis. Any
flare-up of sepsis increases the possibility of breakdown of the anastomosis and of the
abdominal wall closure (leading to dehiscence). However, unnecessary use of antibiotics can
lead to resistance and should therefore be avoided.
Fluid and electrolyte balance with appropriate correction is also important, especially in
patients with adverse factors (eg, high-output fistula).
Patients who develop spontaneous fistula due to disease need appropriate therapy (eg,
infliximab for Crohn disease or antituberculous therapy for tuberculosis) during follow-up to
prevent disease recurrence or recurrence of the ECF. [50] In patients with a malignancy-
related ECF, appropriate chemotherapy and radiation, if required, are administered to control
the primary disease.
After healing of a conventional fistula by spontaneous closure, patients should be informed
that because healing occurs with secondary intention, there is a possibility of development of
an incisional hernia as a long-term complication of ECF.
Other Interventions
Use of fibrin glue and plugs
In a study of 10 patients with low-output (n = 7) or high-output (n = 3) ECFs that had failed to
close after conservative therapy, Rabago et al observed that fibrin glue completely sealed
the majority of ECFs. [51] Once a fistula had been endoscopically located, 2-4 mL of
reconstituted fibrin glue (Tissucol 2.0 at 37°C) was injected through a catheter. The patients
required a mean of 2.5 treatment sessions (range, 1-5), and the mean healing time was 16
days (range, 5-40). After treatment, 87.5% of the low-output fistulas and 55% of the high-
output fistulas sealed completely. No complications occurred.
Issak et al reported a case in which concurrent over-the-scope-closure (OTSC) stent
placement was successfully used in a patient who had a perforated duodenal ulcer with
chronic recurrent ECF. [52] Under fluoroscopic guidance, a fully covered metal stent was
placed into the duodenum.
Truong et al described the use of a polyglactin plug in combination with fibrin glue in the
treatment of ECFs. [53] After the site of an ECF or anastomotic leak was endoscopically
sealed with the plug and glue, seven of the study's nine patients healed completely.
In another study, however, when fibrin glue was introduced directly into an ECF through the
fistula opening in the skin, the results were not encouraging, with the fistula healing in only
one out of eight patients. [33]
Autologous platelet-rich fibrin glue also has been reported to be safe and effective in the
treatment of low-output ECFs by reducing the closure time and promoting closure. [54]
Good results with endoscopic therapy suggest that this technique, when possible, can be
used when other conservative methods fail.
Successful closure of a duodenocutaneous fistula has been reported with the use of the
Biodesign enterocutaneous fistula plug (Cook Medical, Bloomington, IN), which is derived
from a biologic plug used in fistula-in-ano tracts. The plug is introduced into the fistulous tract
percutaneously. [55]
Extracellular matrix enterocutaneous fistula plugs (ECMFPs) are an alternative in patients
with low-flow ECFs, especially when they are not candidates for a surgical procedure. In a
study assessing the use of ECMFPs in 18 patients with enteric fistulas, Smith et al reported
that fistula closure was achieved in 25% of gastrocutaneous fistulas, 44% of
enterocutaneous fistulas, and 50% of colocutaneous fistulas. [56] The median time of fistula
closure was 25-29 days. Recurrence after closure and failure of closure were more common
in patients with high-flow fistulas.
Gelfoam embolization
Lisle et al described successful treatment of three cases of ECF with embolization of
Gelfoam at the enteric opening of the fistula. [57] In this technique, the ECF was assessed by
means of computed tomography (CT) and fistulography to rule out any intra-abdominal
abscess, distal bowel obstruction, active bowel inflammation, or foreign body that would
prevent the fistula from healing. Fistulography also provided information about the fistulous
tract and the site of communication with the bowel.
A 5-French introducer sheath was passed along a guide wire into the tract under fluoroscopy
and then removed, after which Gelfoam strips or pledgets soaked in contrast material were
introduced into the tract through the sheath and pushed down to plug the enteric opening of
the ECF. All of the patients healed completely, with no recurrence of ECF over a 2- to 3-year
follow-up period. [57]
 SURGERY 2

SMALL GROUP DISCUSSION MODULE- SMALL BOWEL

By: Ma. Dulce L. Consuegra, MD, FPSGS, FPCS

SGD Day 1: CASE 1

A 45-year-old female patient was admitted to ER due to abrupt generalized abdominal pain
associated with nausea and vomiting initiated 6 h before hospital referral. She had the history of
two previous abdominal surgeries, including umbilical herniorrhaphy (16 years ago), and
cholecystectomy (a year ago). Physical examination revealed focal tenderness in the midportion
of the abdomen, slight abdominal distention was also seen. She later revealed that she had no
passage of stools for 48 hours but still has occasional passage of flatus.

Vital signs: BP- 100/80; HR- 100; RR-24; T- 37.8 *C

1. List the common causes of a small bowel obstruction . MACABANGON

Small bowel obstruction
-mechanical blockage
-Prevents or reduces the passage of contents

Intraluminal- obstruction within the lumen of the intestine

● foreign bodies
● gallstones ileus
● meconium (neonate)

Intramural- obstruction within thewalls of the small intestines

● tumors
● Crohn’s disease–associated inflammatory strictures
● trauma

Extrinsic- obstruction that resultfrom outside the small intestine

● adhesions
● hernias
● carcinomatosis

CAUSES:
S- Strictures- Inflammatory bowel disorders such as Crohn’s disease or diverticulitis can damage parts of the small
intestine. Complications may include narrowing of the bowel (strictures) or abnormal tunnel-like openings
(fistulas).
H- Hernia- Segments of the intestine may break through a weakened section of the abdominal wall. This creates a
bulge where the bowel can become obstructed if it is trapped or tightly pinched in the place where it pokes
through the abdominal wall. Hernias are the second most common cause of small bowel obstruction in the United
States.
A-adhesion: These are bands of scar tissue that may form after abdominal or pelvic surgery.An earlier abdominal
surgery is the leading risk factor for small bowel obstruction in the United States.
V-volvulus- a condition in which the intestine twists upon itself and its mesentery and causes obstruction, involves
the colon or small bowel. Small-bowel volvulus is more likely in children, whereas colonic volvulus (CV) occurs more
often in adults
I-intussusception- a condition in which one segment of intestine "telescopes" inside of another, causing an
intestinal obstruction (blockage). Although intussusception can occur anywhere in the gastrointestinal tract, it
usually occurs at the junction of the small and large intestines. The obstruction can cause swelling and
inflammation that can lead to intestinal injury.
I-infection-
N-eoplasm- Cancer accounts for a small percentage of all small bowel obstructions. In most cases, the tumor does
not begin in the small intestine, but spreads to the small bowel from the colon, female reproductive organs,
breasts, lungs or skin.
G-allstone- , cause of mechanical bowel obstruction, affecting older adult patients who often have other significant
medical conditions. It is caused by impaction of a gallstone in the ileum after being passed through a biliary-enteric
fistula.

2. Enumerate the common differential diagnosis associated with this case. How will you
rule each one out? RATHOD
3. Describe the classic presentation and physical examination findings of a small bowel
obstruction. Differentiate the types of obstruction. GURO
4. Discuss the diagnostic modalities helpful in small bowel obstruction. What is the clinical
value of each modality? DAGALANGIT
5. Interpret the radiographic films previously given. GHAZALI
6. Describe the treatment priorities for bowel obstruction. BAGUAL
Bowel rest
- Nothing per orem
- reduces hyperactivity in the bowel and decreases vomiting which will limit the
loss of fluids and nutrients, therefore decreasing further malnutrition.
Fluid resuscitation
- Fluid resuscitation is integral to treatment (since small bowel obstruction is
usually associated with a marked depletion of intravascular volume due to increased oral
intake, vomiting, and sequestration of fluid in bowel lumen and wall). Isotonic fluid
 should be given intravenously, and an indwelling bladder catheter may be placed to
monitor urine output
Gastric decompression
- Nasogastric tube decompresses the stomach, minimizes further distention from
swallowed air, improves patient comfort, and reduces risk of aspiration.
- Stomach should be continuously evacuated of air and fluid using nasogastric
tube. Effective gastric decompression decreases nausea, distention, and the risk of
vomiting and aspiration
Close observation and nonsurgical (conservative) management
- Mainstay of treatment for partial bowel obstruction: close observation and
nonoperative management
- Appropriate provided that there is no clinical deterioration and the patient shows
some evidence of improvement over the first 12-24 hrs
- Requires strict hemodynamic monitoring, serial abdominal x rays (every 6 hrs),
and PE (every 3 hrs)
Surgical procedures
- Varies according to etiology of obstruction
- Adhesion: lysis
- Tumors: resection
- Hernias: reduction and repair
- For complete small bowel obstruction: expeditious surgery “sun should never rise
and set on an complete bowel obstruction”
- Rationale for early surgical intervention: minimize the risk for bowel
strangulation, which is associated with an increased risk for morbidity and mortality

Ask preceptor if any additional imaging was done.

7. Discuss the indications for non-operative and operative treatment for SBO. LIBRES
8. How would you prepare the patient pre-op? MACAAYAN

Patient underwent surgery- please ask preceptor what surgery was done
9. Identify which patients are in need of emergent surgical intervention or surgical
consultation. FIEL

● Patients with complete small bowel obstruction generally require expeditious surgery. with a
dictum of “the sun should never rise and set on a complete bowel obstruction.”
● There have been non-operative approaches in management of these patients as long as
closed-loop obstruction is ruled out and there is no evidence of intestinal ischemia. However,
they need to be observed closely and undergo serial exams.
● The goal is to operate before the onset of irreversible ischemia may occur.
● A strangulated obstruction is a surgical emergency as well.
● In patients with a complete small-bowel obstruction, the risk of strangulation is high and early
surgical intervention is warranted.
● Patients undergoing non-operative therapy should be closely monitored for signs suggestive of
peritonitis, the development of which would mandate urgent surgery.
● The administration of hypertonic water-soluble contrast agents like Gastrografin used in upper
gastrointestinal (GI) and small bowel follow-through examinations, causes a shift of fluid into the
intestinal lumen, thereby increasing the pressure gradient across the site of obstruction.
● Patients with simple complete obstructions in whom non-operative trials fail also need
surgical treatment but experience no apparent disadvantage to delayed surgery.
● Overall, the general idea is that if a patient develops signs or symptoms of intestinal
ischemia, they should go to the operating room for exploration.

10. Make your own algorithm on how to manage this patient. MACASAET
SGD Day 2: CASE 2

A 40-year-old male was admitted in the hospital 20 days post-op after developing a partial small
bowel obstruction secondary to multiple abdominal incisional hernias that required repair;
recovery was complicated by the development of multiple intraabdominal abscesses. His history
was significant for a motor vehicle crash dating back to 2002 where he sustained multiple
orthopedic and intra-abdominal injuries that required numerous surgical interventions. Before
transfer to our facility, he underwent lysis of adhesions, repair of multiple hernias and resection
of a loop of small bowel (ileum) with a primary anastomosis after a bowel perforation.

Currently he presented in the ER with a deep wound infection at the inferior pole of the
laparotomy site. He has stable vital signs but show signs of dehydration. Bilious succus fluid was
noted to drain from the wound. Daily wound drainage was estimated to range from 250-330 cc
for the past 4 days.

1. What is ECF? How do we classify ECF? MACASAET

● Fistula is defined as an abnormal communication between two epithelialized surfaces

● Communication occurs between 2 parts of the GI tract or adjacent organs or GI tract with the
skin

○ Internal Fistula - 2 parts of the GI tract or adjacent organ

Ex. Enterocolonic fistula or colovesicular fistula

○ External Fistula- involves the skin or another external surface epithelium

Ex. Enterocutaneous fistula or rectovaginal fistula

Types (Based on the Volume of Output)

● Low output fistulas → Drain less than 200 mL of fluid per day
○ Low-output fistulas are treated medically
■ Lessen passage of fluid → Give TPN, low-residue diet (colocutaneous
fistula), elemental diet (enterocutaneous fistula)

● Moderate output fistulas → Drains between 200 mL and 500mL per day

● High-output fistulas → Drain more than 500mL of fluid per day

○ High-output fistulas are treated surgically unless you can convert it to a
low-output fistula
○ Give Octreotide or Somatostatin → Decrease output

2. Enumerate the risk factors for ECF seen in this case. MACABANGON
1. History of Trauma
2. Post-operative Complications
3. Persistence of local inflammation, abcesses and sepsis
4. Presence of a foreign body (e.g., meshes or sutures)
3. Describe the classic presentation and physical examination findings seen among
patients with probable ECF RATHOD
4. Discuss the imaging modalities that can be helpful in the diagnosis of the case.
GURO
A. CT scan of the abdomen with oral contrast – Most useful initial test
B. Small bowel series or enteroclysis – Used if the anatomy of the fistula is
not clear on CT scan
C. Fistulogram – Contrast is injected under pressure through a catheter
placed percutaneously into the fistula tract to localized the fistula origin

5. Describe the orderly sequence of steps in the treatment of ECF. DAGALANGIT

6. Give some pharmacologic intervention that has a value in the treatment of ECF.
GHAZALI
7. What are the factors affecting the likelihood of ECF closure? BAGUAL
 8. Make a treatment algorithm for this case. LIBRES
ppt: MACAAYAN, FIEL
SGD Day 1: CASE 1

A 45-year-old female patient was admitted to ER due to abrupt generalized abdominal pain
associated with nausea and vomiting initiated 6 h before hospital referral. She had the history
of two previous abdominal surgeries, including umbilical herniorrhaphy (16 years ago), and
cholecystectomy (a year ago). Physical examination revealed focal tenderness in the
midportion of the abdomen, slight abdominal distention was also seen. She later revealed
that she had no passage of stools for 48 hours but still has occasional passage of flatus.

Vital signs: BP- 100/80; HR- 100; RR-24; T- 37.8 *C

1. List the common causes of a small bowel obstruction.(Aguilar)

 2. Enumerate the common differential diagnosis associated with this case. How will you
rule each one out?(Cullantes)

3. Describe the classic presentation and physical examination findings of a small bowel
obstruction. Differentiate the types of obstruction.(Monsanto)

The symptoms of small bowel obstruction are colicky abdominal pain, nausea, vomiting, and obstipation. Vomiting is a more
prominent symptom with proximal obstructions than distal. Character of vomitus is important as with bacterial overgrowth, the
vomitus is more feculent, suggesting a more established obstruction. Continued passage of flatus and/or stool beyond 6 to 12 hours
after onset of symptoms is characteristic of partial rather than complete obstruction.

The signs of small bowel obstruction include abdominal distention, which is most pronounced if the site of obstruction is in the distal
ileum and may be absent if the site of obstruction is in the proximal small intestine. Bowel sounds may be hyperactive initially, but in
late stages of bowel obstruction, minimal bowel sounds may be heard.

partial small bowel obstruction, only a portion of the intestinal lumen is occluded, allowing passage of some gas and fluid.

Complete obstruction the bowel lumen is completely obstructed with no distal passage of stool or air

The management of partial SBO is an initial trial of nonoperative management due to the fact that
progression to strangulation is unlikely. Studies have shown that 60–85 % of patients with partial
obstruction will have resolution of symptoms without the need for surgery. However, if a patient with
partial SBO begins to clinically deteriorate, prompt operative intervention may be necessary. The
management of complete SBO is more controversial. Some of these patients may progress to the point of
strangulation and irreversible ischemia, in which case earl y operation would be favored.

Open-loop obstruction occurs when proximal decompression is possible via emesis or nasogastric tube

A particularly dangerous form of bowel obstruction

closed loop obstruction in which a segment of intestine is obstructed both proximally and distally (e.g., with volvulus). In such
cases, the accumulating gas and fluid cannot escape either proximally or distally from the obstructed segment, lead- ing to a rapid
rise in luminal pressure and a rapid progression to strangulation.
A closed loop obstruction is a particularly dangerous form of bowel obstruction in which a segment of
intestine is obstructed both proximally and distally. Gas and fluid accumulates within this segment of
bowel and cannot escape. This progresses rapidly to strangulation with risk of ischemia and perforation

Closed-loop obstruction occurs when both proximal and distal bowel are obstructed

Strangulation obstruction involves compromise of blood flow with inevitable bowel necrosis
intramural pressure becomes high enough, intestinal microvascular perfusion is impaired leading to intestinal ischemia, and,
ultimately, necrosis

Adhesions after pelvic operations are responsible for more than 60 % of all SBO in the USA, with
appendectomy being the most common cause, followed by colorectal resection, and then gynecologic
procedures. Inflammatory processes such as appendicitis and diverticulitis create adhesions as the
omentum and surrounding intestinal loops attempt to contain the source of inflammation and infection.
Disruption of the visceral and parietal peritoneum with pelvic operations leads to adhesions, especially in
the dependent positions where the loops of small intestine rest. Another possible explanation for this is
that the bowel is more mobile in the pelvis than in the upper abdomen, and thus more likely to produce an
obstruct- ing torsion.

4. Discuss the diagnostic modalities helpful in small bowel obstruction. What is the clinical
value of each modality? (Remitar)
Abdominal X-ray
● Series consist of:
○ Abdominal radiograph in supine and upright position
○ Chest radiograph in upright position
● Sensitivity: 70-80%
● Specificity: Low
● False Negative results when:
○ site of obstruction is in the proximal small bowel
○ bowel lumen is filled with fluid but no gas
● Triad Finding of Small Bowel Obstruction:
○ Dilated small bowel loops (> 3 cm in diameter)
○ Air-fluid levels seen on upright films
○ Paucity of air in the colon
Computer tomographic (CT) scanning
● Imaging of choice for patients with SBO
● Sensitivity: 80-90%
● Specificity: 70-90%
● Done with oral contrast (Oral water soluble contrast or diluted barium)
 ● Findings Include:
○ discrete transition zone with dilation of bowel proximally
○ decompression of bowel distally
○ intraluminal contrast that doesn’t pass beyond the transition zone
○ Colon containing little gas or fluid
*Endoscopy procedure is contraindicated for complete SBO*

5. Interpret the radiographic films previously given.(Sarip) / (Patel)

Notes: The finding most specific for small bowel obstruction is the triad of:

● Dilated small bowel loops (> 3 cm in diameter)

● Air-fluid levels seen on upright films
● Paucity of air in the colon

X-ray abdomen (AP view; supine position). The ascending (green outline), transverse (red
outline), and descending (yellow outline) portions are dilated. Collapse of bowel loops distal to
the obstruction. No gas is seen within the sigmoid colon (indicated in blue overlay). (The
absence of rectal gas raises the possibility of distal mechanical obstruction; however, a
normal posteriorly positioned rectum does not always fill with gas on a supine
radiograph.)
X-ray abdomen (Upright position). It demonstrates multiple air-fluid levels in the dilated loops
in a typical configuration of small bowel obstructions.

6. Describe the treatment priorities for bowel obstruction.(JJ S.)

Fluid resuscitation

● Broad-spectrum antibiotics
● Nasogastric (NG) tube
● Close observation and Non-operative Management
● Water soluble oral contrast
● Operative Procedure
○ Adhesion - lysed
○ Tumors - resected
○ Hernias - reduced and repaired

Ask preceptor if any additional imaging was done.

7. Discuss the indications for non-operative and operative treatment for SBO. (PM S.)
Non-operative management (first 12-24hours)
● Partial small bowel obstruction
● Obstruction occurring in the early postoperative period
● Intestinal obstruction due to Crohn’s disease
● Carcinomatosis
● No clinical deterioration and the patient shows some evidence of improvement over the
first 12 to 12 hours
 ○ Administration of isotonic fluid (IV) and proper hydration of the patient, insertion
of NGT to decompress GI tract
○ Weight out if the patient will eventually pass out flatus or fecal material
○ If the patient happens to show some evidence of progression of bowel
obstruction with the first 12-24 hours, exploratory laparotomy
○ SBP resolve with fluid resuscitation, bowel rest and gastrointestinal
decompression
● Fluid resuscitation
○ Integral to the treatment
○ Isotonic fluid should be given intravenously
○ Indwelling urinary bladder catheter is placed to monitor urine output
○ CVP- placed for critically ill patients (Cardiac disease patients with severe
dehydration)
● Nasogastric tube insertion
○ Evacuates air and fluid
○ When done effectively, it decreases nausea and distention and the risk of
vomiting and aspiration
● Conservative management is preferred, when possible to avoid the risks of operations
○ Resolves acidosis and leucocytosis
○ Antibiotics
○ Nasogastric decompression and supportive care
○ Requires bladder catheterization
Operative management
o Standard therapy for complete SBO
o “The sun should never rise and set on a complete bowel obstruction”
o Rationale – to minimize the risk for bowel strangulation
o Goal is to operate before the onset of irreversible ischemia
o Cases requiring emergent operative management:
● Patients with peritonitis
● Closed loop obstructions
● Strangulation
o Type of obstruction will dictate what surgery you will do:
● Adhesiolysis – if secondary to post-operative adhesion, fibrinous material that can
constrict the small bowel
- Open or laparoscopy
● Tumor resections – segmental resection
● Reduction of hernias – reduce the hernia and repair the hernial sac
● Resection of non-viable bowel – signs of gangrene
o Criteria suggesting bowel viability
● Color: pinkish
● Presence of peristalsis
● Marginal arterial pulsations
● Doppler probe used to check pulsatile flow to the bowel
● Wood’s test: use of fluorescein dye IV, and visualization of the dye in the bowel wall
under UV light

8. How would you prepare the patient pre-op? (Teriote)

● NPO - bowel rest and prevent aspiration of gastric contents resulting from the use of
anesthesia
● Nasogastric tube insertion - evacuates air and fluid, helps the bowel to become
unblocked
● Fluid replacement - to manage dehydration and electrolyte imbalance
● Central venous pressure - to monitor fluid replacement
● Indwelling Foley catheter - to monitor state of hydration/ urine output
● Broad spectrum antibiotics (prophylaxis) - to eliminate microorganisms from trapped
food. also to prevent SS

Patient underwent surgery- please ask preceptor what surgery was done

9. Identify which patients are in need of emergent surgical intervention or surgical

consultation.(Musa)
a. Incarcerated, strangulated hernia
b. Closed loop obstruction (volvulus)
c. Peritonitis
d. Pneumatosis cystoides intestinalis
e. Complete bowel obstruction
f. Pneumoperitoneum

10. Make your own algorithm on how to manage this patient. (All)
SGD Day 2: CASE 2

A 40-year-old male was admitted in the hospital 20 days post-op after developing a partial
small bowel obstruction secondary to multiple abdominal incisional hernias that required
repair; recovery was complicated by the development of multiple intraabdominal abscesses.
His history was significant for a motor vehicle crash dating back to 2002 where he sustained
multiple orthopedic and intra-abdominal injuries that required numerous surgical
interventions. Before transfer to our facility, he underwent lysis of adhesions, repair of
multiple hernias and resection of a loop of small bowel (ileum) with a primary
anastomosis after a bowel perforation.

Currently he presented in the ER with a deep wound infection at the inferior pole of the
laparotomy site. He has stable vital signs but show signs of dehydration. Bilious succus
fluid was noted to drain from the wound. Daily wound drainage was estimated to range from
250-330 cc for the past 4 days.

1. What is ECF? How do we classify ECF?(aguilar)

2. Enumerate the risk factors for ECF seen in this case. (cullantes) (patel)

3. Describe the classic presentation and physical examination findings seen

among patients with probable ECF (mosanto)

enterocutaneous fistulas usually become clinically evident between the fifth and tenth
postoperative days. Fever, leukocytosis, prolonged ileus, abdominal tenderness, and
wound infection are the initial signs. The diagnosis becomes obvious when drainage of
enteric material through the abdominal wound or through existing drains occurs. These
fistulas are often associated with intra-abdominal abscesses.

Classic presentation: Abdominal tenderness, Abdominal Distention , Drainage of enteric

contents which is stain with bile (Bilious succus fluid)- yellow green color or green

PE: findings: Tenderness of the post op site, drainage of enteric contents.

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

4. Discuss the imaging modalities that can be helpful in the diagnosis of the
case.(remitar)

a. CT scanning
● following the administration of enteral contrast
● is the most useful initial test
● Leakage of contrast material from the intestinal lumen can be
observed.
 b. Small Bowel Series or Enteroclysis Examination
● Used when the anatomy of the fistula is not clear on the CT Scan
● special form of x-ray called fluoroscopy and an orally ingested
contrast material called barium.
● demonstrate the fistula’s site of origin in the bowel
● useful to rule out the presence of intestinal obstruction distal to the
site of origin

External opening at the left iliac region. Opacification of

the ileum, cecum and ascending colon

c. Fistulogram
● contrast is injected under pressure through a catheter placed
percutaneously into the fistula tract
● offer greater sensitivity in localizing the fistula origin

water-soluble contrast agent is injected into the fistulous tract

5. Describe the orderly sequence of steps in the treatment of ECF.(sarip)(musa)

The treatment of enterocutaneous fistulas should proceed through an orderly
sequence of steps:

1. Stabilization. Fluid and electrolyte resuscitation has begun. Nutrition is

provided, usually through the parenteral route initially. Sepsis is controlled
with antibiotics and drainage of abscesses. The skin is protected from the
fistula effluent with ostomy appliances or fistula drains.
2. Investigation. The anatomy of the fistula is defined using the
aforementioned studies.
3. Decision. The available treatment options are considered, and a timeline
for conservative measures is determined.
4. Definitive Management. This entails the surgical procedure and requires
appropriate preoperative planning and surgical experience.
5. Rehabilitation.

Stepwise Management of ECF:

1. Identification and treatment of source

- Pharmacologic agents
2. Stabilization
- Fluid resuscitation
- Electrolyte homeostasis
3. Nutritional support
- Enteral feeding VS parenteral feeding
4. Effluent management
- Pharmacologic agents
- Wound care
5. Definitive repair
- spontaneous

6. Give some pharmacologic intervention that has a value in the treatment of

ECF.(JJ)

- Parenteral supplementation compensates for nutrients, water, and

electrolyte losses.
- Somatostatin, a 14-amino acid peptide hormone, inhibits pancreatic
exocrine secretions by decreasing the volume of pancreatic juice.
Somatostatin agonists like Octreotide promotes earlier closure of fistula
than TPN alone, even with malignant enterocutaneous disease, and is
overall helpful in declining secretions in high-output fistulas to a
convenient level.
- Proton pump inhibitors or histamine H2-receptor antagonists decrease
gastric acid production, increase the transit time, and lower gastric
secretions. These drugs help lessen fistula output, chiefly proximal
 fistulas or when there are high gastric secretions. Antiperistaltic agents
like loperamide are useful in lowering intestinal transit times and
decreasing fistula effluents. Refractory fistulas of Crohn's disease are
successfully treated with short courses of cyclosporine and other
immunosuppressive drugs.
- After stabilization is accomplished within 24-48 hours, the investigation
usually takes place over the subsequent 7-10 days. Investigation implies
an intensive evaluation of the digestive tube, definition of the anatomy of
the fistula, and identification of any complicating features like abscess,
stricture, or distal obstruction. Investigative studies should be designed to
work out the presence and location of the fistula and to supply information
regarding its cause.

7. What are the factors affecting the likelihood of ECF closure? (PM)(Sheena) di
ko sure ani pls ko check, cess

Nonhealing ECFs are associated with FRIEND factors:

F - Foreign body

R- Radiation

I - Inflammation, Infection, Inflammatory Bowel Disease

E - Epithelization of the fistula

N - Neoplasms

D - Distal Obstructions

8. Make a treatment algorithm for this case. (all)

SGD Day 3: CASE 3

You are the senior clerk on duty and you arrive in the emergency room. Your attention
was called by the nurse informing you of a 57 -year old female patient. She has a chief
complaint of severe abdominal pain.

The patient tells you that she had right lower quadrant pain that has been getting
worse since yesterday morning. It is associated with lack of appetite, nausea and
vomiting. When you ask her directly, she notes that she initially suffered from mild pain
around her umbilicus night prior. At that time, she also had loss of appetite. However,
this morning, she began having nausea and vomiting and the pain has migrated to her
right lower quadrant.

On your abdominal exam, you noted a non-distended abdomen with direct and
rebound tenderness at the R lower quadrant. A palpable mass was noted on the said
area.

1. What is the pathophysiology of Acute Appendicitis?(Sheena)

Obstruction of the appendiceal orifice is caused by either lymphoid hyperplasia,

infections (parasitic), fecaliths, or benign or malignant tumors. The obstruction then
leads to an increase in intraluminal and intramural pressure of the appendix,
resulting in small vessel occlusion and lymphatic stasis. Once obstructed, the
appendix fills with mucus and becomes distended, and as lymphatic and vascular
compromise advances, the wall of the appendix becomes ischemic and necrotic.
Bacterial, such as E. Coli and Bacteroides fragilis, overgrowth then occurs in the
obstructed appendix, with aerobic organisms predominating in early appendicitis and
mixed aerobes and anaerobes later in the course of the disease.

2. A. Describe the classic history and physical exam findings in appendicitis, as well
as atypical presentations. (musa)
 The atypical symptoms of appendicitis include a dull or sharp pain anywhere in the
abdomen, back, rectum, painful urination, bloating, flatulence, generalized abdominal
tenderness, distension simulating acute intestinal obstruction, enlarging abdominal mass
with or without overlying skin erythema, normal bowel movements, normal vital signs and
even with no pain, no nausea, no vomiting no pyrexia or no weight loss.
Clinical Signs:

B. How will it differ in pregnant patients?(PM)

In early pregnancy, the symptoms of appendicitis are identical to those seen in
the nonpregnant state:
● periumbilical pain that migrates to the right lower quadrant, accompanied by
anorexia
● fever
● nausea, and vomiting.
● With advancing gestational age and in parous women, the diagnosis may
become more challenging, largely due to the laxity of the anterior abdominal wall.
Abdominal pain in pregnancy is less severe than appendicitis and less specific. The abdominal
pain will also shift upward to the right upper quadrant after the first trimester. There is also
nausea and vomiting in pregnancy like appendicitis.
If appendicitis is suspected, diagnostic imaging can help rule in or rule out the diagnosis.
Ultrasound is the test of choice in this setting—the diagnosis of appendicitis is made when a
noncompressible, blind-ended tubular structure greater than 6 mm is visualized in the right
lower quadrant. Unfortunately, the appendix cannot always be visualized with ultrasound, and
ultrasound may be less accurate in the setting of a ruptured appendix or with advancing
gestational age.

3. Enumerate at least 10 differential diagnosis for this patient. Discuss how would
you rule each diagnosis out.(JJ) (monsanto)
● Abdominal Abscess…. CT scan of the abdomen will identify the abdominal
abscess
● Bacterial Gastroenteritis…Abdominal pain and discomfort mostly disappear as
quickly as they come on. Diagnosed by doing stool exam to identify the bacteria
or parasite
● Cholecystitis and Biliary Colic.. diagnosed by doing abdominal ultrasound or
more reliable is ERCP or Endoscopic Retrograde Cholangiopancreatography
● Perforating carcinoma of the cecum or Sigmoid colon… usually in elderly
patients it could be mistaken as appendicitis. Its diagnosed by doing CT scan of
the abdomen
● Crohn Disease…there is abdominal pain, severe diarrhea, fatigue, weight loss
and malnutrition. Colonoscopy is the test to rule in Chrons disease
● Urinary Tract Infection (UTI) and Cystitis (Bladder Infection) in Females.
● Diverticulitis, Do CT scan of abdomen to look for mural thickening of the colon
and presence of pericolic fat stranding
● Ectopic Pregnancy…History reveals missed menstrual period, nausea vomiting,
tiredness frequent urination and vagoinal bleeding. . PE with (+) breast
tenderness, Do pregnancy test to rule in Ectopic pregnancy, Also Ultrasound
● Pelvic inflammatory disease… infection is usually bilateral but can involve only
the right fallopian tube. Motion of the cervix produce severe pain
● Acute Mesenteric Adenitis… is confused with appendicitis in children, but its
associated with upper respiratory tract infection. There is generalized
lymphadenopathy and Lymphocytosis on blood smear.

4. What are the different signs on PE that you can elicit in a patient suspected
with acute appendicitis? What is its clinical significance?(sarip)
 Rovsing’s sign, pain in the right lower quad- rant after release of gentle pressure on left
lower quadrant (normal position); Dunphy’s sign, pain with coughing (retrocecal
appendix); obturator sign, pain with internal rotation of the hip (pelvic appendix);
iliopsoas sign, pain with flexion of the hip (retrocecal appendix). In addition, pain with
rectal or cervical examinations is also suggestive of pelvic appendicitis.

5. Discuss the roles of laboratory tests and imaging in the diagnosis of

appendicitis(Remitar) (patel)
Laboratory Tests : Leukocytosis of 10,000 cells/mm3,
Higher leukocytosis associated with gangrenous and perforated appendicitis (∼17,000
cells/mm3).

C-reactive protein, bilirubin, Il-6, and procalcitonin have all been proposed to aid in the
diagnosis of appendicitis, particularly in the prediction of perforated appendicitis.
In initial stages of appendicitis, a white blood cell (WBC) count and a C-reactive protein
level are two relevant lab tests to get.

A pregnancy test is also essential in women of childbearing age.

A urinalysis can be valuable in ruling out nephrolithiasis or pyelonephritis.

Imaging
a. Computerized Tomography (CT) Scan
● 95% sensitivity and 95% specificity in diagnosing acute appendicitis
● Findings suggestive of appendicitis:
○ Enlarged lumen and double wall thickness (>6 mm)
○ Wall thickening (>2 mm)
 ○ Periappendiceal fat stranding
○ Appendiceal wall thickening
○ Appendicoliths, fecaliths
● Intravenous contrast is generally preferred, but can be avoided in
patients:
○ Allergies
○ low estimated glomerular filtration rate (less than 30 mL/minute for
1.73 m2 )
● Limited use in pregnancy; abdominal shield is needed
* Several meta-analyses have suggested that CT scan is more sensitive
and specific than ultrasound in diagnosing appendicitis*

b. Ultrasound
● sensitivity of 95% and specificity of 95%
● Graded compression ultrasonography is used to identify the
anteroposterior diameter of the appendix.
○ An easily compressible appendix <5 mm in diameter generally
rules out appendicitis.
● Advantage: cheaper and more readily available than CT scan,and does
not expose patients to ionizing radiation
● Disadvantage: user-dependent and has limited utility in obese patients
● Findings suggestive of appendicitis:
○ Thickened periappendiceal wall
○ Diameter >6 mm
○ Pain with compression
○ Presence of an appendicolith
○ Increased echogenicity of the fat
○ (+) periappendiceal fluid
● In addition, graded compression is usually painful for patients with
peritonitis.
 c. Magnetic Resonance Imaging (MRI)
● sensitivity of 95% and specificity of 95%
● expensive test that requires significant expertise to perform and interpret
● Usually recommended in patients for whom the risk of ionizing radiation
outweighs the relative ease of obtaining a contrast CT scan
○ pregnant or pediatric patients

6. How do we do preoperative preparation for a patient with acute

appendicitis?(Monsanto)
7. Enumerate and describe the different surgical approaches for acute appendicitis.
(aguilar/cullantes)
SGD Day 4: CASE 3

Patient underwent surgery- Please ask preceptors what surgery was done

1. What is complicated appendicitis? (Aguilar)

It refers to perforated appendicitis commonly associated with an abscess or phlegmon.

2. Differentiate a peri-appendiceal abscess from a phlegmon. How are they managed?

(patel) (monsanto)

A phlegmon is an inflammatory tumor consisting of the inflamed appendix, its adjacent viscera
and the greater omentum, WHILE an abscess is a pus-containing appendiceal mass.
Traditionally, the phlegmon is managed conservatively with antibiotics followed by interval
appendectomy four to six weeks later.
Periappendiceal abscess is a condition in which an abscess is formed around the appendix as a
result of appendiceal perforation or extension of inflammation to the adjacent tissues due to
aggravation of appendicitis. It occurs in 2-6% of patients with appendicitis.
Periappendicular abscess is generally initially treated conservatively with antibiotic therapy and
if necessary, drainage. Operative treatment in the acute abscess phase is associated with
increased morbidity. Thus a complicated appendicitis with a periappendicular abscess is initially
treated conservatively.

3. What are the recommended antibiotic regimens used in the treatment of Acute
Appendicitis?(cullantes) (sheena)
a. Cefoxitin
b. Ampicillin-Sulbactam
c. Co-amoxiclav
These are the recommendations of the Evidence-Based Clinical Practice
Guidelines on the Diagnosis and Treatment of Acute Appendicitis by the
Philippine College of Surgeons.

4. What is laparoscopic appendectomy? What are the advantages and disadvantages

of this approach?(Remitar) (pm)

This method is less invasive. That means it’s done without a large incision. Instead, from 1 to
3 tiny cuts are made. A long, thin tube called a laparoscope is put into one of the incisions. It
has a tiny video camera and surgical tools. The surgeon looks at a TV monitor to see inside
your abdomen and guide the tools. The appendix is removed through one of the incisions.
Advantages of Laparoscopic Appendectomy over Open appendectomy

1. reduced postsurgical pain

2. fewer incidence of surgical site infection

3. shorter hospital stay,

4. more rapid return to normal activities in adults.

5. Minimal skin incision and faster healing of incision site

Disadvantages of Laparoscopic Appendectomy

1. increased operative time or duration

2. costly operation
3. higher incidence of intra-abdominal abscesses, especially in case of a
perforated appendicitis

5. Enumerate and discuss 5 common complications seen post-appendectomy. Give the

appropriate management for each.(sarip) (musa)
a. Bleeding No blood thinners or anticoagulant meds 2 wks before surgery;
Avoid injury to blood vessels; Ligate or cauterize bleeding vessels
intraoperatively

b. Wound infection Follow strictly aseptic and antisepsis technique pre op,
intra op and post op. Give broad spectrum antibiotics

c. Peritonitis Don’t spill Appendix content intraoperatively. Do thorough

washing if the appendix is ruptured

d. Bowel obstruction Early ambulation postoperatively

e. Injury to nearby organs.. Proper surgical training and instrumentation by

the surgeon

6. What are the essentials in the post-operative follow-up care for patients who
underwent appendectomy? (JJ )

a. Check for signs of surgical site infection

b. Check for fever nausea vomiting
c. Ask for Bowel movement frequency and charater of stools
d. Examine Bowel sounds
 SURGERY 2
MODULE 1
Day 1
MEDICINE 3-C, G4
Bagual, Nicole
Dagalangit, Nihaya
Fiel, Ma. Christine
Ghazali, Jamalul
Guro, Sharina
Libres, Kimberly
Macaayan, Sittie
Macabangon, Rainah
SLIDESMANIA.COM

Macasaet, Nikki
Rathod, Piyush
 Module No. 1
A 45-year-old female patient was admitted to ER due to
abrupt generalized abdominal pain associated with nausea
and vomiting initiated 6 h before hospital referral. She had
the history of two previous abdominal surgeries, including
umbilical herniorrhaphy (16 years ago), and cholecystectomy
(a year ago).
SLIDESMANIA.COM
 Module No. 1
Physical examination revealed focal tenderness in the
midportion of the abdomen, slight abdominal distention was
also seen. She later revealed that she had no passage of
stools for 48 hours but still has occasional passage of flatus.

Vital signs: BP- 100/80; HR- 100; RR-24; T- 37.8 *C

SLIDESMANIA.COM
 LEARNING
OBJECTIVES
SLIDESMANIA.COM
 1. List the common causes of a small bowel obstruction.

Small bowel obstruction

-mechanical blockage
-Prevents or reduces the passage of
contents

Categories:
● Intraluminal
● Intramural
● Extrinsic
SLIDESMANIA.COM
 CAUSES:

S-TRICTURES
H-ERNIAS
A-DHESIONS
V-OLVULUS
I-NTUSSUSCEPTION
I-NFECTION
N-EOPLASMS
G-ALLSTONES
SLIDESMANIA.COM
 2. Enumerate the common differential diagnosis
associated with this case. How will you rule each one out?

● Small bowel obstruction.

● Paralytic ileus.
● Acute appendicitis.
● Large bowel obstruction.
SLIDESMANIA.COM
 PERTINENT SMALL BOWEL PARALYTIC ILEUS ACUTE APPENDICITIS LARGE BOWEL
FINDINGS OBSTRUCTION OBSTRUCTION

History of abdominal + + - +
surgery

Abdominal pain + (central) +/- (Minimal or Absent) + (Right Lower + (Peripheral)

Quadrant)

Vomiting + + + +/- (Minimal or Absent)

Non-bloody diarrhea + + + +

Bowel movement - - - -

Flatus - - + -

Ability to tolerate oral - - -/+ -/+

intake

Distended abdomen + + + +

Tachycardic + + + +
SLIDESMANIA.COM

Bowel sounds Hyperactive Diminished / Absent Hypoactive Normal / Absent

 3. Describe the classic presentation and physical
examination findings of a small bowel obstruction.
Differentiate the types of obstruction.
A. Colicky Abdominal Pain
B. Nausea
C. Vomiting
D. Obstipation
E. Abdominal Distention
F. Bowel sounds may be hyperactive
SLIDESMANIA.COM

G. Mild Leukocytosis
 TYPES OF OBSTRUCTION
A. Partial Small Bowel Obstruction
B. Complete Small Bowel Obstruction
❏ Closed Loop Obstruction
❏ Strangulated Bowel Obstruction
SLIDESMANIA.COM
 4. Discuss the diagnostic modalities helpful in small bowel
obstruction. What is the clinical value of each modality?

Goals:
1. Distinguish mechanical obstruction from Ileus
2. Determine the etiology of the obstruction
3. Discriminate partial from complete obstruction
4. Discriminate simple from strangulation obstruction
SLIDESMANIA.COM
 HISTORY & PE
● Prior Abdominal Operations
● Presence of Abdominal Disorders
● Hernias
SLIDESMANIA.COM
 RADIOGRAPHIC EXAMINATION:
The abdominal series consists:
● A radiograph of the abdomen with the patient in a supine position
● A radiograph of the abdomen with the patient in an upright position
● A radiograph of the chest with the patient in an upright position

The finding most

specific for small bowel
obstruction is the triad
of:
● Dilated small bowel
loops (>3 cm in
diameter)
● Air-fluid levels seen
on upright films
● Paucity of air in the
SLIDESMANIA.COM

colon
 CT SCAN
● test of choice for patients with small
bowel obstruction
● 80% to 90% sensitive and 70% to 90%
specific in the detection of small bowel
obstruction
The findings of small bowel obstruction
include:
● Discrete transition zone with dilation
of bowel proximally
● Decompression of bowel distally
● Intraluminal contrast that does not
pass beyond the transition zone
● Clon containing little gas or fluid
SLIDESMANIA.COM
 5. Interpret the radiographic films previously given.
Notes: The finding most specific for small bowel obstruction is the triad
of:
● Dilated small bowel loops (> 3 cm in diameter)
● Air-fluid levels seen on upright films
● Paucity of air in the colon
SLIDESMANIA.COM
 6. Describe the treatment priorities for bowel obstruction.
● Bowel rest
● Fluid resuscitation

● Gastric decompression
● Close observation and nonsurgical (conservative) management
● Surgical Procedures
○ Adhesiolysis
○ Resection for tumors
○ Reduction and repair of hernias
SLIDESMANIA.COM
 7. Discuss the indications for non-operative and operative
treatment for SBO.
● Non-operative: Malignant tumors, Inflammatory Bowel Disease,
Intra-abdominal Abscess, Radiation Enteritis, Adhesions

● Operative: Strangulated Obstruction is a Medical Emergency

SLIDESMANIA.COM
 8. How would you prepare the patient pre-op?
● Informed Consent
● Patient Education (Explain and set expectations)
● Patient should be on NPO
● IV insertion
● Prophylactic Antibiotics
SLIDESMANIA.COM
 9. Identify which patients are in need of emergent surgical
intervention or surgical consultation.

Patients with:
● Complete bowel obstruction
● Closed loop obstruction
● Suspected or proven intestinal strangulation
● Peritonitis
● Simple complete obstruction (non-operative therapy fails)
SLIDESMANIA.COM
 10. Make your own
algorithm on how to
manage this patient.
SLIDESMANIA.COM
 MEDICINE 3-C, G4

SURGERY 2
Bagual, Nicole
Dagalangit, Nihaya
Fiel, Ma. Christine
Ghazali, Jamalul

MODULE 1
Guro, Sharina
Libres, Kimberly
Macaayan, Sittie
Macabangon, Rainah
Macasaet, Nikki
Rathod, Piyush
 SGD Day 2: CASE 2
A 40-year-old male was admitted in the hospital 20 days post-op after developing a
partial small bowel obstruction secondary to multiple abdominal incisional hernias that
required repair; recovery was complicated by the development of multiple intra-abdominal
abscesses.

His history was significant for a motor vehicle crash dating back to 2002 where he
sustained multiple orthopedic and intra-abdominal injuries that required numerous surgical
interventions. Before transfer to our facility, he underwent lysis of adhesions, repair of
multiple hernias and resection of a loop of small bowel (ileum) with a primary anastomosis
after a bowel perforation.

Currently he presented in the ER with a deep wound infection at the inferior pole of
the laparotomy site. He has stable vital signs but show signs of dehydration. Bilious succus
fluid was noted to drain from the wound. Daily wound drainage was estimated to range from
250-330 cc for the past 4 days.
 01
What is ECF?
How do we classify
ECF?
 ● Fistula is defined as an abnormal communication between
L0 1: two epithelialized surfaces

● Communication occurs between 2 parts of the GI tract or

adjacent organs or GI tract with the skin

○ Internal Fistula - 2 parts of the GI tract or adjacent

organ
Ex. Enterocolonic fistula or colovesicular fistula

○ External Fistula- involves the skin or another external

surface epithelium
Ex. Enterocutaneous fistula or rectovaginal fistula
Types (Based on the Volume of Output)

● Low output fistulas → Drain less than 200 mL of fluid per day
■ Low-output fistulas are treated medically
● Lessen passage of fluid → Give TPN, low-residue diet
(colocutaneous fistula), elemental diet (enterocutaneous fistula)

● Moderate output fistulas → Drains between 200 mL and 500mL per day

● High-output fistulas → Drain more than 500mL of fluid per day

○ High-output fistulas are treated surgically unless you can convert it to a
low-output fistula
○ Give Octreotide or Somatostatin → Decrease output
 Enumerate the risk
02 factors for ECF seen
in this case.
L0 2:
● History of Trauma
● Post-operative Complications
● Persistence of local inflammation,
..
abcesses and sepsis
● Presence of a foreign body (e.g., meshes
or sutures)
 Describe the classic
presentation and physical
03 examination findings seen
among
patients with probable ECF
L0 3:
Enterocutaneous fistulas usually become clinically evident between the fifth and
tenth postoperative days. Fever, leukocytosis, prolonged ileus, abdominal
tenderness, and wound infection are the initial signs. The diagnosis becomes
obvious when drainage of enteric material through the abdominal wound or
through existing drains occurs. These fistulas are often associated with
intra-abdominal abscesses.

Classic presentation: Abdominal tenderness, Abdominal Distention, Drainage of

enteric contents which is stain with bile (Bilious succus fluid)- yellow green
colour.

PE findings: Tenderness of the post op site, drainage of enteric contents.

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.
 Discuss the imaging
modalities that can be
04 helpful in the diagnosis of the
case.
L0 4: IMAGING MODALITIES

A. CT scan of the abdomen with oral contrast

- Most useful initial test

B. Small bowel series or enteroclysis

- Used if the anatomy of the fistula is not clear on
CT scan

C. Fistulogram
- Contrast is injected under pressure through a
catheter placed percutaneously into the fistula
tract to localized the fistula origin
 Describe the orderly sequence
05 of steps in the treatment of
ECF.
L0 5:

The treatment of enterocutaneous fistulas should proceed through an orderly sequence of steps :

1. Stabilization. Fluid and electrolyte resuscitation has begun. Nutrition is provided, usually through the parenteral
route initially. Sepsis is controlled with antibiotics and drainage of abscesses. The skin is protected from the fistula
effluent with ostomy appliances or fistula drains.

2. Investigation. The anatomy of the fistula is defined using the aforementioned studies.

3. Decision. The available treatment options are considered, and a timeline for conservative measures is determined.

4. Definitive Management. This entails the surgical procedure and requires appropriate preoperative planning and
surgical experience.

5. Rehabilitation
 Give some pharmacologic
06 intervention that has a value in
the treatment of ECF.
L0 6:

…
 What are the factors
07 affecting the likelihood of
ECF closure?
 ● Patient factors
L0 7: ○ Poor nutrition
○ Medication (steroids)
● Etiological factors
○ Malignant fistula
○ Fistula related to Crohn’s disease
○ Fistula in radiated fields
● Fistula site
○ Gastric
○ Duodenal
● Local factors
○ Persistence of local inflammation and sepsis
○ Presence of a foreign body (meshes, sutures)
○ Epithelialization of fistula tract
○ Fistula tract <2 cm
○ Distal obstruction to the fistula site
 Make a treatment
08 algorithm for this case.
L0 8: Stabilization: Fluid, Electrolyte, Antibiotics

Investigation: Abdominal CT-Scan,

Fistulogram

Decision: Treatment options are considered

Definitive management: Surgical procedures

Rehabilitation.
 JANUARY FEBRUARY MARCH APRIL MAY JUNE

PHASE 1

Task 1

Task 2

PHASE 2

Task 1

Task 2

JANUARY FEBRUARY MARCH APRIL

PHASE 1

Task 1

Task 2
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 SECTION C - GROUP 3

Enterocutaneous
fistula
 A 40-year-old male was admitted in the hospital 20 days post-op after developing a
partial small bowel obstruction secondary to multiple abdominal incisional hernias that
required repair; recovery was complicated by the development of multiple
intraabdominal abscesses. His history was significant for a motor vehicle crash dating
back to 2002 where he sustained multiple orthopedic and intra-abdominal injuries that
required numerous surgical interventions. Before transfer to our facility, he underwent
lysis of adhesions, repair of multiple hernias and resection of a loop of small bowel
(ileum) with a primary anastomosis after a bowel perforation.

Currently he presented in the ER with a deep wound infection at the inferior pole of the
laparotomy site. He has stable vital signs but show signs of dehydration. Bilious succus
fluid was noted to drain from the wound. Daily wound drainage was estimated to range
from 250-330 cc for the past 4 days.
Entercutaneous Fistula: Definition and its Classification

Fistula is defined as an abnormal communication between two

epithelialized surfaces
Communication occurs between 2 parts of the GI tract or adjacent
organs or GI tract with the skin

Internal Fistula – 2 parts of the GI tract or adjacent organ

o Ex. Enterocolonic fistula or colovesicular fistula
External Fistula – involves the skin or another external surface
epithelium
o Ex. Enterocutaneous fistula or rectovaginal fistula
Types (Based on the Volume of Output)
→
Low-output fistulas Drain less than 200mL of fluid per day
o Low-output fistulas are treated medically

→
Lessen passage of fluid Give TPN, low-residue diet
(colocutaneous fistula), elemental diet (enterocutaneous
fistula)

→
High-output fistulas Drain more than 500mL of fluid per day
o High-output fistulas are treated surgically unless you can
convert it to a low-output fistula
→
o Give Octerotide or Somatostatin Decrease output
Risk Factors for Enterocutaneous Fistula
 Classic Presentation & Physical Examination Findings

enterocutaneous fistulas usually become clinically evident between the fifth and
tenth postoperative days. Fever, leukocytosis, prolonged ileus, abdominal
tenderness, and wound infection are the initial signs. The diagnosis becomes
obvious when drainage of enteric material through the abdominal wound or
through existing drains occurs. These fistulas are often associated with intra-
abdominal abscesses.
Classic presentation: Abdominal tenderness, Abdominal
Distention , Drainage of enteric contents which is stain with bile
(Bilious succus fluid)- yellow green color or green

PE: findings: Tenderness of the post op site, drainage of enteric

contents.
Imaging Modalities

1. CT Scanning
following the administration of
enteral contrast
is the most useful initial test
Leakage of contrast material from
the intestinal lumen can be
observed.
Imaging Modalities

2. Small Bowel Series or

Enteroclysis Examination
Used when the anatomy of the fistula is
not clear on the CT scan
demonstrate the fistula’s site of origin in
the bowel
useful to rule out the presence of
intestinal obstruction distal to the site
of origin
Imaging Modalities

3. Fistulogram
contrast is injected under pressure
through a catheter placed
percutaneously into the fistula tract
offer greater sensitivity in localizing
the fistula origin
Sequence of steps in the treatment of ECF:

Stabilization

Investigation

Decision

Definitive Management

Rehabilitation
Pharmacologic Intervention
Somatostatin
ex. Octreotide
Parenteral Supplementation

Histamine H2-receptor Antagonists/

Proton Pump Inhibitors
Factors Affecting the Likelihood of ECF Closure
Factors Affecting the Likelihood of ECF Closure

FRIEND FACTORS

F - Foreign body
R - Radiation
I - Inflammation, Infection, Inflammatory Bowel Disease
E - Epithelization of the fistula
N - Neoplasms
D - Distal obstruction
Treatment Algorithm

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Thank you!