Fistulas, C47 P305-307

Question 1

What is a fistula?

P305

Answer 1

Abnormal communication between two
hollow organs or a hollow organ and the
skin (i.e., two epithelial cell layers)

Question 2

What are the predisposing
factors and conditions that
maintain patency of a fistula?
P305

Answer 2

The acronym “HIS FRIEND”:
    High output fistula (500 cc/day)
    Intestinal destruction (50% of
       circumference)
    Short segment fistula 2.5 cm

    Foreign body (e.g., G-tube)
    Radiation
    Infection
    Epithelization (e.g., colostomy)
    Neoplasm
    Distal obstruction

Question 3

SPECIFIC TYPES OF FISTULAS
ENTEROCUTANEOUS
What is it?
P305

Answer 3

Fistula from GI tract to skin

entero—cutaneous = bowel to skin

Question 4

SPECIFIC TYPES OF FISTULAS
ENTEROCUTANEOUS
What are the causes?
P306

Answer 4

Anastomotic leak, trauma/injury to the
bowel/colon, Crohn’s disease, abscess,
diverticulitis, inflammation/infection,
inadvertent suture through bowel

Question 5

SPECIFIC TYPES OF FISTULAS
ENTEROCUTANEOUS
What is the workup?
P306

Answer 5

1. CT scan to rule out abscess/
   inflammatory process
2. Fistulagram

Question 6

SPECIFIC TYPES OF FISTULAS
ENTEROCUTANEOUS
What are the possible
complications?
P306

Answer 6

High-output fistulas, malnutrition, skin

breakdown

Question 7

SPECIFIC TYPES OF FISTULAS
ENTEROCUTANEOUS
What is the treatment?
P306

Answer 7

NPO; TPN; drain abscesses, rule out and
correct underlying causes; may feed distally
(or if fistula is distal, feed elemental diet
proximally); half will close spontaneously,
but the other half require operation and
resection of the involved bowel segment

Question 8

SPECIFIC TYPES OF FISTULAS
ENTEROCUTANEOUS
Which enterocutaneous fistula
closes faster: short or long?
P306

Answer 8

Long fistula (may be counterintuitive—
but true)

Question 9

SPECIFIC TYPES OF FISTULAS
COLONIC FISTULAS
What are they?
P306

Answer 9

Include colovesical, colocutaneous,

colovaginal, and coloenteric fistulas

Question 10

SPECIFIC TYPES OF FISTULAS
COLONIC FISTULAS
What are the most common
causes?
P306

Answer 10

Diverticulitis (most common cause),

cancer, IBD, foreign body, and irradiation

Question 11

SPECIFIC TYPES OF FISTULAS
COLONIC FISTULAS
What is the most common
type?
P306

Answer 11

Colovesical fistula, which often
presents with recurrent urinary tract
infections; other signs include
pneumaturia, dysuria, and fecaluria

Question 12

SPECIFIC TYPES OF FISTULAS
COLONIC FISTULAS
How is the diagnosis made?
P306

Answer 12

Via BE and cystoscopy

Question 13

SPECIFIC TYPES OF FISTULAS
COLONIC FISTULAS
What is the treatment?
P306

Answer 13

Surgery: segmental colon resection and
primary anastomosis; repair/resection of
the involved organ

Question 14

SPECIFIC TYPES OF FISTULAS
COLONIC FISTULAS
What is a cholecystenteric
fistula?
P306

Answer 14

Connection between gallbladder and
duodenum or other loop of small bowel
due to large gallstone erosion, often
resulting in SBO as the gallstone lodges
in the ileocecal valve (gallstone ileus)

Question 15

SPECIFIC TYPES OF FISTULAS
COLONIC FISTULAS
What are the common causes
of a gastrocolic fistula?
P307

Answer 15

Penetrating ulcers, gastric or colonic

cancer, and Crohn’s disease

Question 16

SPECIFIC TYPES OF FISTULAS
COLONIC FISTULAS
What are the possible
complications of gastrocolic
fistulas?
P307

Answer 16

Malnutrition and severe enteritis due to
reflux of colonic contents into the stomach
and small bowel with subsequent bacterial
overgrowth

Question 17

SPECIFIC TYPES OF FISTULAS
PANCREATIC ENTERIC FISTULA
What is it?
P307

Answer 17

Decompression of a pseudocyst or abscess
into an adjacent organ (a rare complication);
usually done surgically or endoscopically to
treat a pancreatic pseudocyst

Question 18

SPECIFIC TYPES OF FISTULAS
EXTERNAL PANCREATIC FISTULA
What is it?
P307

Answer 18

Pancreaticocutaneous fistula; drainage of
pancreatic exocrine secretions through to
abdominal skin (usually through drain
tract/wound)

Question 19

SPECIFIC TYPES OF FISTULAS
EXTERNAL PANCREATIC FISTULA
What is the treatment?
P307

Answer 19

NPO, TPN, skin protection, octreotide

Question 20

SPECIFIC TYPES OF FISTULAS
EXTERNAL PANCREATIC FISTULA
What is a “refractory”
pancreatic fistula?
P307

Answer 20

Pancreaticocutaneous fistula that does
not resolve with conservative medical
management (the minority of cases)

Question 21

SPECIFIC TYPES OF FISTULAS
EXTERNAL PANCREATIC FISTULA
What is the diagnostic test
for “refractory” pancreatic
fistulas?
P307

Answer 21

ERCP to define site of fistula tract

i.e., tail versus head of pancreas

Question 22

SPECIFIC TYPES OF FISTULAS
EXTERNAL PANCREATIC FISTULA
How is refractory tail of a
pancreas fistula treated?
P307

Answer 22

Resection of the tail of the pancreas and

the fistula

Question 23

SPECIFIC TYPES OF FISTULAS
EXTERNAL PANCREATIC FISTULA
How is refractory head of a
pancreas fistula treated?
P307

Answer 23

Pancreaticojejunostomy

Question 24

SPECIFIC TYPES OF FISTULAS
BLADDER FISTULAS
What are the specific types?
P307

Answer 24

Vesicoenteric (50% due to sigmoid
    diverticulitis); signs include
    pneumaturia, fecaluria
Vesicovaginal (most are secondary to
    gynecologic procedures); signs include
    urinary leak through vagina