Enterocutaneous Fistula

Classification

Based on the following factors Enterocutaneous fistula is classified as follows:

Different categories are

• Category I: In this category fistula contains single orifice at flat surface of the cutaneous layer and without having much complicated condition.
• Category II: In this category, single or multiple fistula orifice present at the bony distinctions or surgical wound, any others scars or near the umbilicus.
• Category III: It is developed through a small dehiscence which has single orifice from the main scar.
• Category IV: A large dehiscence causes in between two wound develop Enterocutaneous fistula.

On the basis of daily output, it can be classified as:

• When daily output through Enterocutaneous fistula is more than 500ml, then that should be considered as High Output.
• When daily output through Enterocutaneous fistula is in between 200 – 500 ml, then that should be considered as Intermediate Output.
• When daily output through Enterocutaneous fistula is less than 200 ml, then that should be considered as Low Output.

Depending upon the site of development, then it can be considered as gastric, Small intestinal, Large intestinal and rectal enterocutaneous fistula.

Pathophysiology

Following are the pathophysiological condition:

• Electrolyte imbalance: Depending upon the amount of output from the enterocutaneous fistula, the chances of electrolyte imbalance is there. The examination of fluid output is required, as it provide the information about the loss of sodium, bi-carbonate content, and protein content.
• Malnutrition: Malnutrition is another pathophysiology associated with Enterocutaneous fistula. The development of the malnutrition may be due to improper intake of food, Hypercatabolism of the sepsis and loss of protein rich fluid excretion via enterocutaneous fistula.
• Sepsis: Most fatal pathophysiology associated with Enterocutaneous fistula. Different type of bacterial growth can cause development of the sepsis. This is resultant of postsurgical distraction, abscess formation and tissue necrosis.

Symptoms

Symptoms may include

• Intetinal fluid outflow from an abdominal wound on to the cutaneous layer.
• Loose motion
• Pain in abdomen
• Fever
• Chills (If infection is associated)
• Increase heart beat
• Dehydration due to loss of fluid and electrolytes

Causes

The most common cause is resultant of intestinal surgery. Other than this, the following are the reasons of development.

• Irritable bowel syndrome
• Crohn’s disease
• Perforated duodenal ulcer
• Ulcerative colitis
• Trauma
• Malignancy
• Radiotherapy followed in cancer therapy

Diagnosis

For enterocutaneous fistula diagnosis, initial physical examination is very important and depending upon the physical condition following tests is conducted for confirmation:

If fistula developed at colon then barium enema test is conducted

• CT scan
• Esophagram. Usually before X-ray, swallowing of barium is very important and then multiple series of X-rays are conducted which helps to take proper images of esophagus. The administration of barium causes changes in the shape of the esophagus.
• Fistulogram: In this process the dye in penetrated at the opening of the fistula skin and X-rays are taken.

Management & Repair

Enterocutaneous fistula creates multiple complexities, which can be manageable by participating all the healthcare providers including clinicians, nursing staff, enterostomal therapists and dietician. According to the patient condition healthcare staff prepare proper treatment plan for particular patient.

The wound associated cannot heal naturally with time, it need complex surgical intervention for cover the fistula opening and again connection is re-established in the gastrointestinal tract. The management of Enterocutaneous fistula, it is necessary to step wise treatment plan:

Step 1. Identification and stabilizing the patient deteriorating condition

In this step, after diagnosis, if enterocutaneous fistula is detected, then fluid loss related complications should be controlled. For this reason, intravenous fluid intervention, controlling the fluid leakage and caring of the associated cutaneous layer are very important steps.

Step 2. Nutritional management:

After establishing these steps, next major clinical concern is nutritional supply to overcome the malnutrition problem. Water-soluble vitamins, electrolyte replenishment and calorie adjustment is required to manage the condition.

Step 3. Underlying cause and complications identification:

The presence of Crohn’s disease, uncontrollable sepsis and malignancy presence may complicate the enterocutaneous fistula. Identification and management of these conditions is very important prior to operation. Usually in case of severe infection, due to immunosuppression and impaired wound healing, it is necessary to control the condition and possible antibiotic therapy or other treatment management is applied according to the need.

Step 4, Surgical Interventions:

Dissection of intestine with various invented method which include meticulous technique, ligament of Treitz to the rectum may perform.  Resection and end-to-end anastomosis also included intervention method.

Step 5, Healing:

Post-operative care is very important to heal the wound fast. Thus patient’s nutritional care and proper dressing of wound fasten the wound healing.

Pictures

References

1. The pathophysiology of fistulas at http://link.springer.com/article/10.1007%2FBF01655932#page-1
2. Enterocutaneous Fistula Lab studies, Surgery, Skin Management, Drainagae ar http://emedicine.medscape.com/article/1372132-overview
3. http://www.ncbi.nlm.nih.gov/books/NBK6914/
4. Enterocutaneous Fistula(Gastrointestinal Fistula; Entero-enternal Fistula) Definition, Risk Factors, Prevention at http://www.ucsfhealth.org/conditions/enterocutaneous_fistula/
5. Enterocutaneous Fistulas Symptoms, Signs, Diagnosis, Treatment at http://health.cvs.com/GetContent.aspx?token=f75979d3-9c7c-4b16-af56-3e122a3f19e3&chunkiid=577660
6. Definitive Surgical Treatment of Enterocutaneous Fistula at http://archsurg.jamanetwork.com/article.aspx?articleid=1379762