Fistula Management

Question 1

Fistula: Initial Indications

Answer 1

Non-specific: fever and ABD pain
Definitive: GI secretions into wound or unintentional opening
pH of effluent suggests origin of fistula

Question 2

Fistula: Etiologic Factors

Answer 2

Anastomotic breakdown
2nd IBD, Cancer, diverticulitis
Complicated by malnutrition, sepsis, hypotension, vasopressors, corticosteroids

Question 3

Spontaneous fistulas

Answer 3

25%
2nd intrinsic intestinal disease (radiation, appendicitis), trauma
Resistent to spontaneous closure
+ risk w/ pelvic cancer 2nd to radiation

Question 4

Iatrogenic Fistula

Answer 4

75%
Anastomotic breakdown
Surgical risk factors: - blood supply, poor suturing, lysis of adhesions

Question 5

Fistula Medical Management

Answer 5

Spontaneous closure: 6-8 weeks
- output
Maintain F/E balance
Control infection
Nutritional support
Definition of fistula tract
Contain effluent

Question 6

Fistula: F/E Balance

Answer 6

8-10 L lost through jejunum w/ 98% reabsorbed (100-200mL excreted)
Proximal small bowel = + output
Colon = - output
H, Cl, Na, K lost
- oral and enteral intake
H2 antagonist (cimetidine) = - secretions

Question 7

Fistula: Nutritional support

Answer 7

Maintain positive Nitrogen balance
TPN and bowel rest
4ft healthy bowel needed for entered feedings

Question 8

Stomatized Fistula (Pseudostoma)

Answer 8

Anterior bowel wall become adherent to ABD wall
Fistula tract undergoes mucosal eversion
Permanent opening = surgery needed to close

Question 9

Fistula Effluent

Answer 9

Left transverse/descending: Odorous, semi-formed, - damaging to skin