ENTEROCUTANEOUS FISTULA – 3
Fistula: Abnormal communication between two epitheliazed surfaces
Enterocutaneous Fistula: Abnormal communication between bowel and skin
Etiology:
• 75%-80% occur as a postoperative complication
o anastomotic leak(50%): devascularization, systemic hypotension, tension at on
anastomosis, anastomosis performed in diseased bowel
o Inadvertent injury to the bowel (50%):
• 15% - 25% occur spontaneously
o
Crohn’s disease (5%-50%) Fistulas occur in 20-40% of Crohn’s patients with
half of these being external. A result of transmural inflammation leading to
adherence of the involved bowel to abdominal wall, microperforation, abscess
formation and eventual fistula formation
o Radiation, cancer, diverticular disease, appendix
Presentation:
• Classic postoperative presentation:
o Prolonged ileus, febrile, erythematous wound
o POD 7-10 purulence followed by enteric contents from wound.
Radiographic evaluation:
• CT with IV and oral gastrograffin contrast to evaluate for abscesses with or without
percutaneous drainage
o Subsequent abcessograms should be performed 2-5 days after drain placement
and then weekly until drain is removed
o Fistula are usually not demonstrated at the time of initial drainage, but become
evident on subsequent abcessograms after the cavity has been cleared debris and
decreased in size
o Aggressive attempts to demonstrate a fistula at the time of initial drainage
increases the risk of sepsis
o A fistula should be suspected if drainage exceeds 30-50 ml per day after 2-3 days
• Fistulogram using gastrograffin contrast locate the fistula
Classification:
• Anatomic: The more proximal the fistula, the greater the fluid, electrolyte and nutritional
deficit
• Output:
o Low = less than 200cc/24 hours
o Moderate = 200-500cc/24 hours
o High = greater than 500cc/24 hours
o Output is an independent predictor of patient death, but is not prognostic of
eventual closure
o Most useful in planning nutrition, fluid, and electrolyte managem