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GASTROINTESTINAL FISTULA

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Title: GASTROINTESTINAL FISTULA


1
GASTROINTESTINAL FISTULA
  • By Assistant Lecturer
  • Mohamed Seif

2
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.
3
CLASSIFICATION OF GI FISTULAS
4
  • 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.

5
  • 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.

6
CAUSES OF ACQUIRED GI FISTULAS
                                             
                  
7
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.

8
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.

9
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 )

10
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.

11
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.

12
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).

13
  • 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

14
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).
15
  • Crohns disease with ileo-sigmoid fistula
    Rectosigmoid fistula

16
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.
17
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.
18
  • 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.

19
  • Gastrocolic fistula (arrowhead), which at
    surgery, proved to be secondary to diverticulitis

20
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.

21
  • 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.

22
  • 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.

23
  • 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.

24
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.

25
EXTERNAL (CUTANEOUS) FISTULAS
  • Enterocutaneous fistula. pelvic fistulogram in
    abdominal tuberculosis shows enterocutaneous
    fistula (arrowheads). Note second cutaneous
    fistula (arrow) that communicates with injection
    site.

26
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