Intestinal

Fistulae
Prof. J. Adwok, MBChB,
MMED(Surg.), FCS(ECSA), FRCS, Ph.D.
Department of Surgery
University of Nairobi

5/10/2010 MBChB V Lecture 1

 Definition
 A fistula is a
communication
between two epithelial
or endothelial surfaces.

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5/10/2010 MBChB V Lecture
 Classification of Intestinal
Fistulas
•Acquired fistulas, e.g.
entero-cutaneous
fistulas
•Congenital fistulas--
tracheo-oesophageal
fistulas.

5/10/2010 MBChB V Lecture 3

 Classification of Intestinal
Fistulas—Cont.
 External or entero-cutaneous
which open to the skin
 Internal fistulae that affect
adjacent organs
• Entero-enteric
• Entero-colic
• Entero-vesical
5/10/2010 MBChB V Lecture 4
 Aetiology of
External Fistulas
•Leakage of
anastomosis
•Unrecognize

d injury
•Accidental

injury
5/10/2010 MBChB V Lecture 5
 Aetiology of Internal Intestinal
Fistulae
Underlying gastrointestinal
lesion
– Colonic diverticular disease
– Chron’s disease
– Colonic carcinoma
– Radiation enteritis
– Intestinal TB.
– Chronic Cholecystitis
5/10/2010 MBChB V Lecture 6
 Clinical presentation of external
fistulas
Postoperative fever and
prolonged ileus
Leakage of faecal material
from surgical, stab, bullet
wound or drain site
Septic shock
5/10/2010 MBChB V Lecture 7
 Presentation of
entero-vesical
Fistula

•Bladder
irritability
•Dysuria

•Faecaluria

•Pyuria

•Pneumaturi

a
5/10/2010 MBChB V Lecture 8
 Investigations
TBC
Serum Albumin
Electrolytes
Blood culture
Urine analysis and
culture
5/10/2010 MBChB V Lecture 9
 Imaging
 CT. Scanning
 Fistulogram
 Small bowel follow-through
 Oral methylene blue
 Oral activated charcoal
 Upper GIT endoscopy
 Cystoscopy
5/10/2010 MBChB V Lecture 10
 Treatment of Intestinal
Fistulae
 Conservative
 Nutritional support
 Meticulous collection of
fistulous discharge
 Skin stoma care
 Control of sepsis
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5/10/2010 MBChB V Lecture
 Nutritional Support
 Significant impact in patients with GI
fistulas
 Patients with localized infection and
malnutrition require 30-40Kcal/kg/day
 Uncontrolled sepsis, shock and multiple
organ failure require 40-45Kcal/kg/day.
 Proteins are administered as amino acids
and not included in caloric calculations
 1.5-2.5 gm/kg/day of protein is required to
ensure replacement of enteric losses
5/10/2010 MBChB V Lecture 12
 Nutritional Support—Cont.
 Fluids and electrolytes are maintained by
frequent monitoring of serum electrolytes
and replacement of losses
 Add trace elements and vitamins to
parenteral and enteral formulas to prevent
deficiencies
 Enteral feeding is initiated orally or via
catheter placed distal to fistula after initial
TPN alimentation to stabilize patient
 72% of fistulas close spontaneously with
adequate nutritional support with a mortality
of only 12% compared to 55% and 19% when
nutritional support is poor.
5/10/2010 MBChB V Lecture 13
 Collection of
Fistulous
Discharge

Placement of
soft sump drain
Connection to
low suction
drain through
ileostomy bag

5/10/2010 MBChB V Lecture 14

 Pharmacological Support
 Histamine receptor antagonists (e.g.
famotidine) can reduce proximal secretions
from stomach.
 The Somatostatin analogue—octreotide—can
significantly reduce fistula output. 200-300
mcg subcutaneously 8 hourly can reduce
output by as much as 50% in 24-48 hours.
 Patients with chronic inflammatory
conditions like chron’s disease benefit from
anti-inflammatory drugs like cyclosporine
and azathioprine
5/10/2010 MBChB V Lecture 15
 Indications for Surgery
 Depend on physiological, anatomical,
and aetiological factors.
 Many enterocutaneous fistulae close
spontaneously when infection is
controlled, adequate nutritional
support is given and distal obstruction
is not present.
 Surgery is indicated only in stable
patients with positive nitrogen
balance and normal protein indices
 A minimum of 3-6 weeks is required
to make a decision
5/10/2010 MBChB V Lecture 16
5/10/2010 MBChB V Lecture 17
 Indications for Surgery
 Early surgery is rarely required but
may be indicated in:
• Sepsis or abscess formation not amenable
to percutaneous drainage
• Complete distal intestinal obstruction
• Uncontrolled bleeding from fistula
• Removal of mesh or other foreign bodies
• Inability to control the fistula without
surgical drainage

5/10/2010 MBChB V Lecture 18

 Indications for Surgery
Delayed surgery is most commonly indicated
in patients whose fistulas have not healed
after several weeks (typically 4-8 wk) of
comprehensive conservative treatment.
Specific indications include the following:
– Continued high output from fistula after patient
has been given nothing by mouth and started on
parenteral nutrition
– Continued signs of infection after institution of
adequate antibiotic therapy and drainage of
associated abscesses

5/10/2010 MBChB V Lecture 19

Entero-enteric
Fistulas
By-Pass of
Fistulous
loops
Ileo-
transverse
anastomosis
to by-pass
fistulous
loops
5/10/2010 MBChB V Lecture 20
 Entero-Vesical Fistulas
 Medical treatment consists of
nutritional support and
treatment of urinary tract
infection with broad-spectrum
antibiotics. Definitive Treatment
is surgical resection of the
fistula, involved intestine, and
bladder wall.
5/10/2010 MBChB V Lecture 21
 Summary
 Intestinal fistulas could be congenital or
acquired and are either external or
internal
 Acquired external fistulas result from
surgical anastomotic leakage or trauma.
Internal fistulas arise from underlying
GIT lesions
 Most fistulas close spontaneously with
proper nutritional and pharmacological
support
 Surgery is indicated to treat immediate
complications and when conservative
treatment fails.
5/10/2010 MBChB V Lecture 22