Gastrointestinal

Fistulas

Presented by :Mousa Mohammad

Mashagbah
 Definition
• Fistulas are abnormal
communications between two
epithelial-lined surfaces.
• Gastrointestinal (GI) fistulas
represent abnormal ductlike
communications between the gut
and another epithelial-lined
surface, such as another organ
system, the skin surface, or
elsewhere along the GI tract itself.

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 CLASSIFICATION OF GI
FISTULAS

GI fistulas can be categorized as

external or cutaneous if they
communicate with the skin surface
or internal if they connect to
another internal organ system or
space, including elsewhere along
the GI tract itself.

Internal GI fistulas can be further

divided into two types: intestinal
and extraintestinal.

Intestinal fistulas refer to a gut-to-

gut connection .

Extraintestinal internal fistulas

imply communication of the GI
tract with another organ system.

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 CAUSES OF GI FISTULAS
(1)
Fistulae can be divided into
congenital (present from
birth) and acquired types.
The former is rare and is
often associated with other
congenital abnormalities
such an anus that is not
completely patent.

The underlying causes of

acquired GI fistulas are
diverse and can include
virtually any process
resulting in bowel
perforation from within or
bowel penetration from an
extraintestinal process .
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 CAUSES OF GI FISTULAS(2)
* Approximately 15% to 25% of fistulas are associated with
inflammatory processes (diverticulitis, inflammatory bowel disease),
cancer, or radiation treatment.

*Fistula formation is a hallmark of Crohn disease, occurring in up to

20%–40% of patients described in surgical series .

*Colorectal cancer is perhaps the most common malignancy

associated with enterovesical fistulae. This occurs because the
cancer spreads through the bowel wall to adhere and invade the
adjacent bladder.

*The remaining 75% to 85% of GI fistulas are related to postoperative

surgical procedures (anastomotic dehiscence, erosion by an adjacent
drain, unrecognized iatrogenic injury) .

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INTERNAL GI FISTULAS
A- Intestinal Fistulas
*Intestinal fistulas may involve any or all combinations of the
small bowel, colon, and stomach.

*The clinical manifestation of this subset may be subtle, since

only the alimentary tract is involved. Diarrhea, with or without
abdominal pain, is the most common symptom overall.

*There are several factors that influence which segments of

bowel are involved in the fistulous communication:
1-Proximity to the pathologic process.
2-a preexisting or preferred pathway between certain portions
of the gut, as with a connecting ligament or mesentery.

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 A- Intestinal Fistulas(e.g.)

*Enteroenteric and enterocolic fistulas are common

complications of Crohn disease, where fistulas are often
multiple and favor the ileocecal region.

*Enterocolic fistulas in Crohn disease are usually due to

primary small-bowel disease, whereas the opposite is true for
colonic diverticulitis.

*gastrocolic fistula:
The gastrocolic ligament allows for bidirectional spread of
pathologic processes between the greater curve of the
stomach and the transverse colon. Although carcinomas of
the stomach and colon were once thought to be the most
common cause of gastrocolic fistula, it now appears that
most cases are due to penetrating benign gastric ulcers,
particularly in the setting of nonsteroidal antiinflammatory
drug use.
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 Enteroenteric and
enterocolic fistulas
• A-Frontal radiograph from
barium-enhanced small-
bowel study in a 25-year-
old man with Crohn
disease shows multiple
fistulous tracts extending
from the terminal ileum
(arrowheads), converging
to a small mesenteric
cavity (∗), and
communicating with the
cecum and more proximal
ileum (arrows).

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 B-Extraintestinal Fistulas

*The extraintestinal fistulas constitute a diverse collection of

acquired GI fistulas since they can connect the gut with virtually any
other organ system. Extraintestinal fistulas involving the
genitourinary, biliary, vascular, and respiratory systems .

A-Genitourinary tract:
The bladder and vagina are most often affected, but involvement of
the upper collecting system, urethra, or uterus is occasionally seen.

*e.g. The term enterovesical fistula is often generally applied for

bladder communication with the colon, small bowel, rectum, or
appendix .Sigmoid diverticulitis is the single most common cause of
enterovesical fistula.

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 Colovesical fistula:
Transverse contrast-
enhanced CT scans in a
56-year-old-man with
pneumaturia and prior
diverticulitis show air
(arrowhead) in the
bladder and the site of
fistulous communication
(arrow) between
sigmoid colon and
bladder.

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• B-Biliary tract.
• Spontaneous internal biliary fistulas
represent a complication of
cholelithiasis or choledocholithiasis in
over 90% of cases . Infrequent causes
include peptic ulcer disease,
malignancy, and prior surgery.
• The clinical manifestation of
enterobiliary fistulas is often
nonspecific, and most cases are
diagnosed on the basis of an
unsuspected imaging finding.

• Pneumobilia seen on imaging studies

strongly suggests the presence of an
internal biliary fistula in the absence
of prior surgery.

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• C-vascular system:

• Enteric fistulas involving the

vascular system, whether arterial
or venous, are potentially lethal
and require urgent correction.

• he aorta lies in proximity with the

GI tract for much of its thoracic
and abdominal course. Aortoenteric
fistulas, therefore, can potentially
involve the gut anywhere from the
esophagus to the colon .The
majority of cases occur in the
presence of aortic aneurysm
disease

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• D-Respiratory tract:

• Acquired esophagorespiratory fistulas

account for the majority of
intrathoracic GI fistulas and consist of
communication with either the
tracheobronchial tree or the pleura.

• Fistulas that communicate between

the respiratory tract and the
intraabdominal GI tract (ie,
gastrobronchial, enterobronchial, and
colobronchial fistulas) are rare but
may result from a penetrating
subphrenic abscess or a postsurgical
complication.
• Likewise, gastropleural and
colopleural fistulas are also rare and
are usually associated with
diaphragmatic herniation or after
pulmonary resection

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 EXTERNAL (CUTANEOUS)
FISTULAS
• the majority of unintended enterocutaneous fistulas
represent a complication of prior surgery.
Diverticulitis, appendicitis, Crohn disease, and
other causes.
• Perianal fistulas are somewhat unusual in that most
appear to be idiopathic in nature or due to Crohn
disease.
• Factors that predispose to postoperative
enterocutaneous fistula formation include
anastomotic failure (eg, due to inadequate blood
supply, diseased bowel), adjacent abscess
formation, distal obstruction, and certain
underlying disease processes

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 • Enterocutaneous fistulas are further
categorized according to their degree of
fluid production. High-output fistulas drain
more than500 mL/day and generally
originate in the upper GI tract, whereas
low-output fistulas drain less than this
amount and are typically more distal.

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 Gastrocutaneous fistula
Transverse contrast-
enhanced CT scan in a 65-
year-old woman with
Crohn disease shows
unsuspected
gastrocutaneous fistula (F).
Note soft-tissue thickening
(arrowheads) of the
abdominal wall and
stomach. A focal
abdominal bulge was
initially thought at clinical
examination to be a
ventral hernia because
overlying skin was still
intact at that time.

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 Diagnostic Studies
• Cross-sectional imaging, and conventional contrast-
enhanced studies provide complementary
information that allows comprehensive evaluation
of most acquired GI fistulas.
• Despite this wide variability, some broad comments
can be made with regard to the imaging approach.
• A- Contrast-enhanced fluoroscopic examinations
often remain the initial study of choice and are
generally superior to endoscopy in demonstrating
the presence and extent of a GI fistula.
• Fistulography is adequate for diagnosis of most
external (cutaneous) fistulas and is also useful for
follow-up in these cases.

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 Diagnostic Studies(2)
• The fistulogram is performed by inserting a soft catheter into
the fistula and then instilling the contrast dye.
• A series of radiographic studies of the GI tract are then
performed to identify the site of the fistula in the GI tract, the
tract between the GI tract and the skin (simple vs. complex),
and the patency of the GI tract distal to the fistula.

• For extraintestinal internal fistulas, one must decide between

pursuing a primary bowel study and a study that directly
opacifies the communicating organ system, such as urography,
vaginography, cholangiography, and others.

• For intestinal (gut-to-gut) fistulas, enteric contrast-enhanced

studies are superior and may be the only noninvasive method
able to demonstrate these fistulas in some cases.

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Diagnostic Studies(3)
• Cross-sectional imaging, particularly computed
tomography (CT), has further strengthened the
radiologist’s for evaluating GI fistulas.

• CT effectively complements conventional

radiography with its ability to demonstrate
extraluminal disease, including associated
abscesses, tumor, or other coexisting processes.

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Treatment
• Medical management of patients with GI fistula
should include maintaining fluid and electrolyte
balance, providing bowel rest and nutrition support,
initiating medication treatment, ensuring skin
protection.
• Affected patients have an inadequate absorption of
nutrients, and are at risk for dehydration and
electrolyte imbalances. The electrolytes sodium,
potassium, magnesium, and phosphate must be
replaced either through total parenteral nutrition
(TPN) or intravenous therapy.
• Initiation and maintenance of nutrition are essential
for treating patients with GI fistulas. Bowel rest by
keeping the patient NPO is recommended for at
least 4 to 8 weeks .
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• When indicated, enteral nutrition is preferred to avoid
atrophy of the mucosal villi and allows for normal bowel
function. Choosing to support the patient with enteral or
parenteral nutrition is based upon the anatomical location of
the fistula.

• Medical management also includes the use of pharmaceutical

agents which assist in decreasing the fistula output.
E.g.Octreotide (Sandostatin[R]) can decrease fistula output by
inhibiting the release of gastrin and other GI hormones. This
decreases secretions of bicarbonate, water, and pancreatic
enzymes into the intestine, thus decreasing intestinal volume.
• Fibrin glue is another medical treatment used to close or seal
up a low-output fistula. The glue is composed of fibrinogen
and thrombin which form a gel when mixed together. The gel
is endoscopically injected onto the fistula tract to create a
seal .

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• Reference :
• radiology.rsna.org.
• findarticles.com.
• Minei, J., & Champine, J. (2002). Abdominal
abscesses and gastrointestinal fistulas. In M.
Feldman, L. Friedman, & M. Sleisenger (Eds.),
Gastrointestinal and liver disease:
Pathophysiology/diagnosis/management (7th ed.)
(pp.431-437).

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 Thank you

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