GASTROINTESTINAL FISTULA

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GASTROINTESTINAL FISTULA

• By Assistant Lecturer
• Mohamed Seif

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Definition
A fistula is defined as an abnormal communication
between two epithelialised surfaces
Gastrointestinal (GI) fistulas represent
abnormal duct like communications between the gut
and another epithelial-lined surface, such as
another organ system, the skin surface, or
elsewhere along the GI tract itself. A GI sinus
tract, in comparison, is a similar duct like
passage that communicates with the gut at one end
but ends blindly at the other.
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CLASSIFICATION OF GI FISTULAS
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• 70 of properly managed external fistulae will
  close spontaneously
• Spontaneous closure is more likely if
• -Bowel continuity is maintained
• -There is no abscess
• -The adjacent bowel is healthy and there is no
  distal obstruction
• -The fistula tract is not epithelialized or more
  than 2 cm in length
• -The bowel defect is less than 1 cm in diameter.
  
• Gastric, lateral duodenal, ligament of Treitz and
  ileal fistulae are the least likely to close with
  non-operative therapy.

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• Furthermore external fistulae can be classified
  as to output.
• High-output fistulae discharge more than
  500ml/day low-output less than this.
• In the case of pancreatic fistulae a high-output
  fistula is one which produces more than 200
  ml/day.
• High output fistulae lead to more serious
  metabolic disturbances and have higher mortality
  rates.

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CAUSES OF ACQUIRED GI FISTULAS
                                             
                  
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Clinical Spectrum

• External fistulae may be obvious when fluid
  discharges, associated with abdominal pain and
  tenderness, ileus, fever and leukocytosis. The
  enteric nature of the discharge is diagnostic. If
  there is doubt, methylene blue ingestion may
  confirm the initial suspicion.
• Internal fistulae are likely to be more subtle
  with symptoms of sepsis, diarrhea, rectal
  bleeding, weight loss and exacerbation of the
  underlying disease. Obstruction may arise from
  gallstone ileus through a cholecystoduodenal
  fistula pneumaturia and recurrent UTI are
  indicative of an enterovesicle fistula.

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Diagnosis
The goal is to make a precise anatomic
classification of the fistula.

• The patients general condition, electrolytes and
  nutritional status including albumin all should
  be assessed.
• Further diagnostic work-up includes
• -Upper and lower GI endoscopy
• -Upper and lower intestine radiography with
  water soluble contrast medium
• -Fistulography with flourosocopy is especially
  useful and is likely to be most widely available.
• -Ultrasound and CT or MRI scanning where
  available.
• -In extraintestinal fistula, additional imaging
  techniques may be necessary
• biliary tree ERCP,
• bladder cystoscopy, pyelography and
  cystograms.

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General Principles of Management Phase 1-
Recognition and Stabilization

• Fluid resuscitation, correcting serum
  electrolytes and acid base imbalances
• Controlling sepsis which is the major cause of
  mortality.
• Controlling and reducing fistula output
• Protecting skin and wound care
• Nutritional support (most important factor )

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Phase 2- Investigation and Assessment

• The fistulogram is the most important procedure.
  
• The following information be derived
• (1) the source of the fistula
• (2) the nature (length, course, and
  relationships) of the
• fistula tract
• (3) the absence or presence of bowel
  continuity
• (4) the absence or presence of distal
  obstruction
• (5) the nature of the bowel adjacent to
  the fistula (inflammation, stricture)
• (6) the absence or presence of an abscess
  cavity in communication with the fistula.

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Phase 3 Treatment Plan

• Somatostatin and analogues (In external high
  output Fistula)
• -They shows a decrease in time of closure when
  used with other treatments, such as nutritional
  support.
• -The recommendation is that, they should be used
  in high output fistulae. If there is no reduction
  in fistula output in 48 hours they should be
  stopped.
• Definitive surgeryResection of the fistula and
  primary anastomosis
• Definitive surgery should not be undertaken if
  there is undrained sepsis or serum
  albumin
• Emergency surgery is confined to draining
  abscesses, and inserting feeding tubes.

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Infliximab Therapy

• Before the introduction of infliximab,
  antibiotics were the only nonsurgical treatment
  for fistulae, and often needed to be given for a
  long time, leading to side effects and
  noncompliance. Infliximab has dramatically
  improved the management of fistulizing CD.
• External fistulae in general and perianal
  fistulae in particular have a higher rate of
  closure compared to other types of fistulae.
• However, fistulous tracts may persist, and may
  cause recurrent fistulae and pelvic abscesses.
• TNF is a key player in the immune response.
  Inhibition by IFX could potentially lead to
  serious postoperative complications. However,
  published literature has not yet shown this to be
  the case (Gut 2006).

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• Prognosis
• The outcome of gastrointestinal fistulae has
  changed dramatically over the years with the
  introduction of intensive care and the provision
  of nutritional support.
• The most important factor correlating with high
  mortality is the volume of fistula output

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Enteroenteric and enterocolic fistulas. (a)
barium-enhanced small-bowel study in Crohn
disease shows multiple fistulous tracts extending
from the terminal ileum (arrowheads), converging
to a small mesenteric cavity (), and
communicating with the cecum and more proximal
ileum (arrows).
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• Crohns disease with ileo-sigmoid fistula
  Rectosigmoid fistula

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Colocolic (double-tracking) fistula. (a)
air-contrast barium enema examination 1 month
after an episode of acute diverticulitis shows a
long-segment narrowing (arrowheads) involving the
sigmoid colon. At the distal aspect of the
stricture, a second channel (arrow) parallels the
colonic lumen, the so-called double-tracking
sign. Note additional scattered diverticula.
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Enterocolic fistula. air-contrast barium enema
shows communication between sigmoid colon and
small bowel (arrowheads). Note also faint
contrast agent (arrow) extending along aortic
region.
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• Gastrocolic fistulas.
• Barium enema shows fistulous communication
  between the transverse colon and stomach via a
  large benign gastric ulcer ()
• Note smooth folds radiating from the ulcer crater
  and absence of a gastric or colonic mass.

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• Gastrocolic fistula (arrowhead), which at
  surgery, proved to be secondary to diverticulitis

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Extraintestinal Fistulas

• Fluoroscopic image shows contrast agent injection
  through a communicating enterocutaneous fistula
  and demonstrates the fistula (arrowhead) between
  the ileal segment and bladder.
• Small-bowel adenocarcinoma complicating Crohn
  disease was proved at surgery.

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• Rectovesical fistula.
• CT scan in ulcerative colitis shows air in a
  fistulous tract (arrow) between inflamed rectum
  and bladder. Note also air (arrowheads) in
  bladder lumen.

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• Rectovaginal fistula.
• air-contrast barium enema in a woman with
  ulcerative colitis shows air and contrast agent
  within the vagina (V). The site of communication
  (arrow) is visible inferiorly.

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• Cholecystocolic fistula. barium enema examination
  shows contrast agent within the gallbladder ()
  from communication with the hepatic flexure. Air
  (arrowheads) is present within the biliary tree.

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Respiratory tract

• Tracheoesophageal and bronchoesophageal fistulas.
  
• (a) Barium esophagogram in man with esophageal
  cancer shows contrast agent delineating
  tracheoesophageal communication (arrowhead). Note
  widening of tracheoesophageal stripe () and mass
  effect on the trachea from tumor.
• (b) barium esophagogram in a man with recurrent
  pneumonia shows fistula (arrow) between esophagus
  and airway that was secondary to histoplasmosis.

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EXTERNAL (CUTANEOUS) FISTULAS

• Enterocutaneous fistula. pelvic fistulogram in
  abdominal tuberculosis shows enterocutaneous
  fistula (arrowheads). Note second cutaneous
  fistula (arrow) that communicates with injection
  site.

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Thank You