1. ENTERO-CUTANEOUS FISTULA
Dr Sadia Shabbir
House Surgeon
Surgical unit 1

2.  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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3. Anatomical classification:
(1)
Internal:Two organ of same or different system
▪ Enteroenteral, enterovesical,enterocolic,
External: Gut to body surface.
▪ Gastrocutaneous,duodenocutaneous,
enterocutaneous.
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4. (2)
Simple or direct.
Complicated-
1.Having multiple tracts
2. Connection with more
than one viscus
3. drainage into an
associated abscess
cavity.

5.  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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6. • 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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7. • Operations for
perforations
• Acute intestinal
obstruction
• Intestinal
malignancies
• Adhesiolysis
• Blunt and penetrating
abdominal trauma
.
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8. 3. Congenital
 Tracheo- esophageal
 Rectovaginal
 Umbilical fistula.
4.Traumatic
 Blunt and penetrating trauma of abdomen, chest
and perineum
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9.  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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10.  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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11.  Malnutriton
 Infection
 Hypotension
 Anemia
 Hypothermia
 Poor oxygen delivery
 Mobilisation
 Handling
 Tension
 Ischemia
 hemostasis
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12.  Fluid and electrolyte imbalance.
 Malnutrition
 Sepsis
 Skin irritation and excoriation
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13.  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.

14.  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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15. THE GOAL are
 Re-establishment of bowel continuity
 Ability to achieve oral nutrition
 Closure of the fistula
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16. PHASE TIME COURSE
RECOGNITON /
STABILISATION
24TO 48 HRS
INVESTIGATON 7- 10 DAYS
DECISION 10 DAYSTO 6 WEEKS
DEFINITIVE
MANAGEMENT
WHEN CLOSURE UNLIKELY OR
4-6WKS
HEALING 5 – 10 DAYS AFTER CLOSURE
UNTILL FULL ORAL NUTRITON
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17.  Resuscitation
 Control of sepsis
 Electrolyte repletion
 Control of fistula drainage
 Local skin care n protection
 Provision of nutrition
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18.  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

19.  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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20.  Restrict hypo-osmolar fluids
 Encourage electrolyte mix
 Antisecretory agents
 Proton pump inhibitors
 Somatostatin or octreotide
 Antimotility agents
 Loperamide
 Codeine
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21.  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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22.  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
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23.  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

24. Wound pouch dressing
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26. Nutritional management
 Plays Central role in management
 Adequate circulation and tissue oxygenation must
for optimal utilization.
 May be:
▪ Enteral
▪ Parenteral
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27. 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
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28.  Fistulogram
 MRI
 Barium transit studies
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29. 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.

30. Entero colic fistula Sigmoid cutaneous fistula
Gastro cutaneous fistula
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31.  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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32.  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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33.  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
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34.  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.