Overview of enteric fistulas
- Sharon L Stein, MD, FACS, FASCRS
Sharon L Stein, MD, FACS, FASCRS
- Associate Professor of Surgery
- University Hospitals/Case Medical Center
- Section Editors
- Eileen M Bulger, MD, FACS
Eileen M Bulger, MD, FACS
- Section Editor — Trauma Surgery
- Professor of Surgery
- University of Washington
- J Thomas Lamont, MD
J Thomas Lamont, MD
- Editor-in-Chief — Gastroenterology/Hepatology
- Section Editor — Anorectal Disorders and Misc. Lower GI Disease
- Section Editor — Nutrition, Malabsorption, and Misc. Upper GI Disease
- Professor of Medicine
- Harvard Medical School
- David I Soybel, MD
David I Soybel, MD
- Editor-in-Chief — General Surgery
- Section Editor — Upper GI Surgery
- David L. Nahrwold Professor
- Penn State Hershey Medical Center
A fistula is an abnormal connection between two organs. Enteric fistulas are abnormal connections between the gastrointestinal tract and other abdominal organs, chest, or skin. Symptoms associated with fistulas depend on whether the fistula is proximal (eg, stomach, jejunum) or distal (eg, ileum, colon) and may include diarrhea for entero-colonic or enteroenteric fistulas; urinary tract infections for fistulas to the urinary system; or external drainage of enteric contents for enterocutaneous or entero-atmospheric fistulas.
The treatment of fistulas requires optimization of nutrition and healing potential, and definitive surgical treatment, when indicated. Many enteric fistulas may heal spontaneously. Nonoperative interventions such as endoscopic or interventional radiology can be used for temporary or definitive management of fistulas. During evaluation, a thorough consideration of the etiology of the fistula, removal of precipitating factors, optimization of nutritional status, and primary treatment of fistulas should occur. Up to 25 percent of mortality from fistulas occurs as a result of infection and sepsis related to complications from fistulas. Additional mortality is often due to fluid and nutritional losses secondary to uncontrolled fistula output. Immediate surgery may be required in the setting of uncontrolled sepsis.
An overview of the clinical features, diagnosis and management of enteric fistulas is reviewed here. Other enteric fistulas, including pancreatic fistulas, are introduced briefly below, but reviewed in more detail in separate topic reviews. (See "Pancreatic fistulas: Clinical manifestations and diagnosis" and "Pancreatic fistulas: Management" and "Urogenital tract fistulas in women" and "Rectovaginal and anovaginal fistulas" and "Anorectal fistula: Clinical manifestations, diagnosis, and management principles".)
DEFINITION AND CLASSIFICATION
A fistula is an abnormal communication between two structures.
Enteric fistulas can be classified as internal or external depending upon whether they drain externally to the skin or internally to the gastrointestinal tract or other organ (eg, bladder, vagina). Enteric fistulas are also classified with respect to the anatomic segments of bowel (ie, other organs or vascular structures) that are involved .
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- DEFINITION AND CLASSIFICATION
- ETIOLOGY AND RISK FACTORS
- - Open abdomen
- CLINICAL FEATURES
- DIFFERENTIAL DIAGNOSIS
- INITIAL MANAGEMENT
- Fluid therapy
- Treatment of infection
- Nutritional support
- CONTROLLING EXTERNAL FISTULA OUTPUT
- Bag drainage
- Pharmacologic therapy
- - Anticathartics
- - Somatostatin analogues
- Negative pressure wound therapy
- Enteroatmospheric fistula
- - Superficial
- - Deep
- FISTULA CLOSURE WITH CONSERVATIVE MANAGEMENT
- INDICATIONS FOR FISTULA RESECTION
- Incision and adhesiolysis
- Fistula resection
- Special circumstances
- - Duodenal fistula
- - Urogenital tract fistulas
- Abdominal wall closure or reconstruction
- INFORMATION FOR PATIENTS
- SUMMARY AND RECOMMENDATIONS