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ENTEROCUTANEOUS FISTULA - 2
Definition:
Abnormal communication between two epithelialized surfaces
Most occur after operation/instrumentation
Foreign body, radiation, iatrogenic, IBD, infection, epithelialization, perforation,
neoplasm, diverticular disease, distal obstruction
IBD – close, only to open later
More common in emergency surgery
Work up:
CT, contrast studies (enemas, fistulagram, small bowel series)
Classification:
Scheme
Classification
Favorable
Unfavorable
Anatomic
Esophageal,
duodenal stump,
pancreatobiliary,
jejunal, or
pharyngeal, small
leak, tract > 2 cm,
defect < 1 cm2
Gastric, lateral
duodenal, ligament
of Treitz, ileal,
complete disruption,
epithelialization,
distal obstruction,
poor adjacent bowel
Physiologic
Low output
Moderate
High
? low output
? 3X spontaneous
closure
Etiology
Disease process
Appendicitis,
diverticulitis,
postoperative
Cancer, IBD, foreign
body, radiation
Management:
Depends on 24 hour output
Independent prognostic factor of mortality
Low = < 200 mL/ 24 hr
Moderate = 200 mL – 500 mL
High = > 500 mL/ 24 hour
Low Output
High Output
Form of nutrition
Enteral
Parenteral
Protein
1 – 1.5 g/kg/d
1.5 – 2.5 g/kg/d
Calories
Resting energy
Resting energy X 1.5
Lipids
Enteral – 20-30%
Parenteral 20-30%
Vitamins
RDA, 2X Vit C
2X RDA,
5-10X Vit C
Minerals
Mg, Phos, Na, HCO3, Zn, K
107
Surgical resection, correction of cause (obstruction, etc)
Flaps/grafts
Drainage
Diversion
Medications
H2 blockers/PPI – decrease acid production and volume
Somatostatin – decrease pancreatobiliary and GI output
? Healing process
Antibiotics
Remicaide
Glues
Skin care
VAC dressings
Appliances
Creams/powders
Bowel rest
NG tube/NPO