enterocutaneous fistula
TRANSCRIPT
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A Fistula is defined as an abnormal communication between two epithelized surfaces.
Enterocutaneous fistulas (ECFs) are abnormal communications between the bowel and skin
Morality rate of 6.5 to 21%.
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CLASSIFICATION
Anatomical classification:(1)
Internal: Two organ of same or different system
▪ Enteroenteral, enterovesical,enterocolic,
External: Gut to body surface.
▪ Gastrocutaneous,duodenocutaneous, enterocutaneous.
(2)
Simple or direct.
Complicated-
1.Having multiple tracts
2. Connection with more than one viscus
3. drainage into an associated abscess cavity.
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Physiological classification
High output- output more than 500 ml/ day
Moderate output- output 200-500 ml/day
Low output- output less than 200ml/day
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Etiologic Classification
• Radiation
• Inflammatory bowel disease
• Diverticular disease
• Appendicitis
• Ischaemic bowel disease
• Duodenal ulcer perforation
• Malignancies
• Intestinal tuberculosis
• Actinomycosis.
1. Spontaneous(15-25%)-
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2. Post-operative (75-85%)
• Operations for perforations
• Acute intestinal obstruction
• Intestinal malignancies
• Adhesiolysis
• Blunt and penetrating abdominal trauma
.
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3. Congenital Tracheo- esophageal Rectovaginal Umbilical fistula.
4. Traumatic Blunt and penetrating trauma of
abdomen, chest and perineum
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ETIOLOGY
Disease bowel extending to surrounding structures
Extraintestinal disease involving otherwise normal bowel
Trauma to normal bowel including inadverent or missed enterotomies
Anostomotic disruption following surgery for a vareity of conditions
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Small intestinal fistula are most common type of gastrointestinal fistulas encountered.
Most series report 70%-90-% of small intestinal fistulas occurs after an operative procedure.
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Factors Influencing
Malnutriton Infection Hypotension Anemia Hypothermia Poor oxygen
delivery
Mobilisation Handling Tension Ischemia hemostasis
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Pathophysiology
Fluid and electrolyte imbalance.
Malnutrition
Sepsis
Skin irritation and excoriation
Clinical presentation
Recognized 5th-10th days post operatively.
Fever
Leucocytosis
Prolonged ileus
Abdominal tenderness
Drainage of enteric material through the abdominal wound or through or existing drains.
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Avg. Time to closure
Varies with anatomical location
1. Esophageal- 15-25 days
2. Duodenal- 30-40 days
3. Colonic - 30- 40 days
4. Small Bowel- 40-60 days
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MANAGEMENT
THE GOAL are Re-establishment of bowel continuity Ability to achieve oral nutrition Closure of the fistula
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MANAGEMENT PHASES
PHASE TIME COURSERECOGNITON / STABILISATION
24 TO 48 HRS
INVESTIGATON 7- 10 DAYS
DECISION 10 DAYS TO 6 WEEKS
DEFINITIVE MANAGEMENT
WHEN CLOSURE UNLIKELY OR 4-6 WKS
HEALING 5 – 10 DAYS AFTER CLOSURE UNTILL FULL
ORAL NUTRITON
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Recognition / stabilization
Resuscitation Control of sepsis Electrolyte repletion Control of fistula drainage Local skin care n protection Provision of nutrition
Resuscitation
Restoration of normal circulating blood volume
Correction of electrolyte & acid base imbalance.
Plasma oncotic pressure should be restored by exogenous albumin administration. - 3 mg/dl
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Control of Sepsis
Management of local wound infections
Drainage if Intra-abdominal collections (percutaneous)
Laparotomy may be required for: Extensive cellulitis/necrotising fascitis Incomplete percutaneous drainage of collections Disruption of anastomosis
Antibiotics as per indicated
CVP only after 24 hrs of drainage
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Reduction of fistula output
Restrict hypo-osmolar fluids Encourage electrolyte mix Antisecretory agents
Proton pump inhibitors Somatostatin or octreotide
Antimotility agents Loperamide Codeine
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Somatostatin and analouge
Naturally occuring peptide hormone Inhibitory to gastrointestinal
secrection Plasma half life 1-2 min Mode
Inhibit gastrin n cholecystokinin Reduces splanchic blood flow Reduces rate gastric emptying Inhibit gall bladder contraction
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Skin care management:
Problems in skin around the fistula: Wetness Burning pain Discomfort from skin edema
Goals of skin care: Containing the effluent Patient independence and mobility
T
Skin Barriers
Solid wafers (pectin based)
Powders (Pectin / Karaya based)
Paste
Spray and wipes
Ointments and creams (zinc/petroleum based)
Wound pouch dressings
One/two piece design
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Nutritional management
Plays Central role in management
Adequate circulation and tissue oxygenation must for optimal utilization.
May be:▪ Enteral ▪ Parenteral
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INVESTIGATION (7-10 days)
Objectives of investigation plan: To define-
Precise anatomical location
Is the bowel in continuity or is disrupted
Abscess cavity
Condition of adjacent bowel
Is there a distal obstruction
Etiological disease process
CT fistulogram
By using water soluble gastrograffin is the investigation of choice
length and diameter of the tract site of bowel wall defect health of the adjacent bowel, and the presence of strictures abscess cavities distal obstruction anastomotic dehiscence.
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Endoscopic studies
Gastro duodenoscopy : Demonstrates both underlying disease and presence of fistula.
Colonoscopy : Fistula is usually not visible but presence of disease and its nature by biopsy can be demonstrated.
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DECISION: (10 days – 6 wks)
No signs of imminent closure after 4- 6 weeks then patient should be prepared for surgery
Uncontrolled sepsis urgent drainage of sepsis.
General condition very poor then only abscess drainage
In case of malignancies early operation should be done.
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DEFINITIVE MANAGEMENT
Optimal nutrition parameters Free of sepsis Well healed abdominal wall without
inflammation Prophylactic antibiotics Tapering of tube feeding Prevent contamination of abdominal wall
tissues Treat the cause
Factors possibly responsible for failure of spontaneous closure are:
a. Foreign Body b. Radiation c. Inflammation/ infection d. Epithelialisation
[F-R-I-E-N-D-S] e. Neoplasm f. Distal intestinal obstruction g. Steroids.