This document discusses enterocutaneous fistulas, abnormal connections between the skin and gut. The ileum is the most common site of origin. Management is based on the principles of stabilization, nutrition, anatomy evaluation, and treatment planning. Low output fistulas (<500 ml/day) may heal spontaneously but high output fistulas require further intervention like surgery to close the fistula tract. Careful surgery can help prevent iatrogenic fistula formation, which accounts for the majority of cases.

1. ENTERO CUTANEOUS FISTULA

2. Normally, fistula is defined as an abnormal
communication between two epithelized
surface.But enterocutaneous fistula is an
abnormal communication between the skin with
various parts of the gut. The ileum is the most
common site of origin of enterocutaneous fistula.

4. A. Pre operative:
1. Previous abdominal surgery
2. Malnourished patient
3. Surgery for IBD
4. Septic patient or acute sepsis
5. Steroid use(more than 10gm/dl)
6. Intra abdominal abscess

5. Perioperative-
1. Shock patient
2. Extensive adhesiolysis
3. Injudicious anastomosis
Post operative:
1. Repeat laparotomy

6. A. Anatomical classification:
 Internal or external fistula- internal fistulae
are named after the structures it
communicates like gastrocolic , jejunoileal,
aortoenteric fistula
B. Physiological classification:
Based on output- High output > 500
ml/day(usually from small gut)
Low output- <500 ml/day(usually colonic)

7.  Primary or type-1 fistula:
It developed as a result of underlying
disease affecting the gut wall.such as…..
1. Neoplasm of gut.
2. Crohn’s disease
3. Ulcerative colitis
4. Intestinal TB
Secondary or type-2 fistula:
It occurs after injury to otherwise normal gut.
Example: During surgery, Penetrating
trauma,Radiation enteritis

8. 1.Low output fistula ( <500ml/day ) is
expected to heal spontaneously, provided
there is no distal obstruction.
2. High output fistula(>500 ml/day) is
difficult to manage as because less chance
of spontaneous heal.

9. Overall this management based on well
established principle ‘’SNAP’’
S= Stabilization, sepsis control, skin care
N= Nutrition
A= Anatomy of the fistula evaluation
P= Plan to deal with fistula

10. Stabilization, sepsis control, skin care:
1. The first step to management is the
resuscitation and stabilization of the patient
by intravenous fluid, strict input and output
measurements are essential and CVP
monitoring and urinary catheterization are
especially helpful, ongoing fluid loss should
be fully replaced and electrolyte imbalances
must be corrected.

11. 2. Control of sepsis by judicious use of
antibiotic
3. Attention should also be given to any intra
abdominal / subcutaneous abscesses and if
present, they should be drained.
4. Skin protection by vacuum dressing or
repeated dressing and in skin damage use zinc
oxide paste.

12. Nutrition:
Nutritional support needs to begin as soon as
the patient is stabilized. Nutrition can be
given by parenteral or enteral route, based on
the anatomy of the fistula.
Nutrition via the enteral route is best as
because it helps in maintaining the intestinal
mucosal barrier, more efficacious delivery of
nutrients ,stimulating hepatic protein
synthesis.

13. TPN(Total parenteral nutrition is also given in
patients who need nutritional support more than 2
weeks or do not tolerate enteral feeds or have long
standing ileus or before fistulous tract is well
established.
Calorie requirement according to type of fistula,
for low output fistula- 30 to 35 kcal/kg/day. For
high output 45 to 50 kcal/kg/day and protein 1.5 -
2.5 gm/kg/day and twice the daily requirement of
vitamins trace elements, zinc.

14. Pharmacological agents used to in the
management of fistula:
1. Somatostatin analogue octreotide
2. Proton pump inhibitors and H2 receptor
antagonists.

15.  To define the anatomy of fistula, stabilization
is first needed then investigations to
determine the presence and localization of
fistula, it’s cause and presence of
comorbidities.
 Types of imagines are
1. Fistulography ( more common and popular
here)
2. CT scan of the abdomen with IV and oral
contrast
3. MRI
4. For small bowel origin- small bowel follow
through contrast study.

16. As previous slide I mentioned that low output
fistula closed spontaneously. Now the factor
responsible for spontaneous closure of
fistula:
1. Well nourished patient
2. No sepsis
3. No distal obstruction
4. Tract less than 2 cm.
5. Long and narrow tract for the fistula.

17. Majority (80-90)% will close within 6 weeks with
consurvative management.
But in case of faecal fistula or high output fistula
or fistula not heal within 6 weeks it is bettre to
wait upto 10-12 weeks. In this period patient
should be nutritionally optimized, should not
be septic and should be vitally stable. Then
definitive treatment such as surgery is
planned.

18. 1. Restoration of intestinal
continuity either resection
anastomosis or stoma formation.
2. Reconstruction of the abdominal
wall defect.

19. 1. Resection of fistulas part then
either primary anastomosis or
construction of a stoma which may
be temporary or permanent
2. For abdominal wall closure, if
primary closure not achieved then
use mesh to repair or component
separation technique.(Ramirez)

20. 1. Daily blood test for S.electrolytes,
magnesium
2. Monitoring fistulas output.
3. Urine output.

21. 1. Care, meticulous surgery to avoid
iatrogenic injury to the gut.
2. Avoid excessive adhesiolysis.
3. Optimize patient condition.
4. Serosal tears should be examined
carefully and repaired if required.

22. Majority of the enterocutaneous fistula are due
to iatrogenic causes( 70-85)%. So careful
during surgery is essential and education
about enterocutaneous fistula is important to
manage such cases.