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Overview of enteric fistulas

Sharon L Stein, MD, FACS, FASCRS
Section Editors
Eileen M Bulger, MD, FACS
J Thomas Lamont, MD
David I Soybel, MD
Deputy Editor
Wenliang Chen, MD, PhD


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".)


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 [1].


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Literature review current through: Sep 2016. | This topic last updated: Jan 23, 2015.
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  1. Berry SM, Fischer JE. Classification and pathophysiology of enterocutaneous fistulas. Surg Clin North Am 1996; 76:1009.
  2. Schecter WP, Hirshberg A, Chang DS, et al. Enteric fistulas: principles of management. J Am Coll Surg 2009; 209:484.
  3. Hollington P, Mawdsley J, Lim W, et al. An 11-year experience of enterocutaneous fistula. Br J Surg 2004; 91:1646.
  4. Osborn C, Fischer JE. How I do it: gastrointestinal cutaneous fistulas. J Gastrointest Surg 2009; 13:2068.
  5. Burlew CC, Moore EE, Cuschieri J, et al. Sew it up! A Western Trauma Association multi-institutional study of enteric injury management in the postinjury open abdomen. J Trauma 2011; 70:273.
  6. Hu D, Ren J, Wang G, et al. Persistent inflammation-immunosuppression catabolism syndrome, a common manifestation of patients with enterocutaneous fistula in intensive care unit. J Trauma Acute Care Surg 2014; 76:725.
  7. Majercik S, Kinikini M, White T. Enteroatmospheric fistula: from soup to nuts. Nutr Clin Pract 2012; 27:507.
  8. Al-Khoury G, Kaufman D, Hirshberg A. Improved control of exposed fistula in the open abdomen. J Am Coll Surg 2008; 206:397.
  9. Bradley MJ, Dubose JJ, Scalea TM, et al. Independent predictors of enteric fistula and abdominal sepsis after damage control laparotomy: results from the prospective AAST Open Abdomen registry. JAMA Surg 2013; 148:947.
  10. Bassi C, Dervenis C, Butturini G, et al. Postoperative pancreatic fistula: an international study group (ISGPF) definition. Surgery 2005; 138:8.
  11. Alexander ES, Weinberg S, Clark RA, Belkin RD. Fistulas and sinus tracts: radiographic evaluation, management, and outcome. Gastrointest Radiol 1982; 7:135.
  12. Kwon SH, Oh JH, Kim HJ, et al. Interventional management of gastrointestinal fistulas. Korean J Radiol 2008; 9:541.
  13. Chun HB, Baek IH, Lee MS, et al. Jejunocolic fistula associated with an intestinal T cell lymphoma. Gut Liver 2011; 5:387.
  14. Park MS, Kim WJ, Huh JH, et al. Crohn's duodeno-colonic fistula preoperatively closed using a detachable endoloop and hemoclips: a case report. Korean J Gastroenterol 2013; 61:97.
  15. Savvidou S, Goulis J, Gantzarou A, Ilonidis G. Pneumobilia, chronic diarrhea, vitamin K malabsorption: a pathognomonic triad for cholecystocolonic fistulas. World J Gastroenterol 2009; 15:4077.
  16. Dellinger RP, Levy MM, Carlet JM, et al. Surviving Sepsis Campaign: international guidelines for management of severe sepsis and septic shock: 2008. Crit Care Med 2008; 36:296.
  17. Rivers E, Nguyen B, Havstad S, et al. Early goal-directed therapy in the treatment of severe sepsis and septic shock. N Engl J Med 2001; 345:1368.
  18. Fulcher AS, Turner MA. Percutaneous drainage of enteric-related abscesses. Gastroenterologist 1996; 4:276.
  19. Dudrick SJ, Maharaj AR, McKelvey AA. Artificial nutritional support in patients with gastrointestinal fistulas. World J Surg 1999; 23:570.
  20. Stanga Z, Brunner A, Leuenberger M, et al. Nutrition in clinical practice-the refeeding syndrome: illustrative cases and guidelines for prevention and treatment. Eur J Clin Nutr 2008; 62:687.
  21. Polk TM, Schwab CW. Metabolic and nutritional support of the enterocutaneous fistula patient: a three-phase approach. World J Surg 2012; 36:524.
  22. Kudsk KA. Immunonutrition in surgery and critical care. Annu Rev Nutr 2006; 26:463.
  23. Kudsk KA, Minard G, Croce MA, et al. A randomized trial of isonitrogenous enteral diets after severe trauma. An immune-enhancing diet reduces septic complications. Ann Surg 1996; 224:531.
  24. Schilling J, Vranjes N, Fierz W, et al. Clinical outcome and immunology of postoperative arginine, omega-3 fatty acids, and nucleotide-enriched enteral feeding: a randomized prospective comparison with standard enteral and low calorie/low fat i.v. solutions. Nutrition 1996; 12:423.
  25. Bower RH, Cerra FB, Bershadsky B, et al. Early enteral administration of a formula (Impact) supplemented with arginine, nucleotides, and fish oil in intensive care unit patients: results of a multicenter, prospective, randomized, clinical trial. Crit Care Med 1995; 23:436.
  26. Lloyd DA, Gabe SM, Windsor AC. Nutrition and management of enterocutaneous fistula. Br J Surg 2006; 93:1045.
  27. Martinez JL, Luque-de-Leon E, Mier J, et al. Systematic management of postoperative enterocutaneous fistulas: factors related to outcomes. World J Surg 2008; 32:436.
  28. Bressler B, Sands BE. Review article: Medical therapy for fistulizing Crohn's disease. Aliment Pharmacol Ther 2006; 24:1283.
  29. Coughlin S, Roth L, Lurati G, Faulhaber M. Somatostatin analogues for the treatment of enterocutaneous fistulas: a systematic review and meta-analysis. World J Surg 2012; 36:1016.
  30. Rahbour G, Siddiqui MR, Ullah MR, et al. A meta-analysis of outcomes following use of somatostatin and its analogues for the management of enterocutaneous fistulas. Ann Surg 2012; 256:946.
  31. Draus JM Jr, Huss SA, Harty NJ, et al. Enterocutaneous fistula: are treatments improving? Surgery 2006; 140:570.
  32. Alivizatos V, Felekis D, Zorbalas A. Evaluation of the effectiveness of octreotide in the conservative treatment of postoperative enterocutaneous fistulas. Hepatogastroenterology 2002; 49:1010.
  33. Wiedermann CJ, Reinisch N, Braunsteiner H. Stimulation of monocyte chemotaxis by human growth hormone and its deactivation by somatostatin. Blood 1993; 82:954.
  34. Lattuada D, Casnici C, Crotta K, et al. Inhibitory effect of pasireotide and octreotide on lymphocyte activation. J Neuroimmunol 2007; 182:153.
  35. Boulanger K, Lemaire V, Jacquemin D. Vacuum-assisted closure of enterocutaneous fistula. Acta Chir Belg 2007; 107:703.
  36. Cro C, George KJ, Donnelly J, et al. Vacuum assisted closure system in the management of enterocutaneous fistulae. Postgrad Med J 2002; 78:364.
  37. Banwell P, Withey S, Holten I. The use of negative pressure to promote healing. Br J Plast Surg 1998; 51:79.
  38. Wainstein DE, Fernandez E, Gonzalez D, et al. Treatment of high-output enterocutaneous fistulas with a vacuum-compaction device. A ten-year experience. World J Surg 2008; 32:430.
  39. Rao M, Burke D, Finan PJ, Sagar PM. The use of vacuum-assisted closure of abdominal wounds: a word of caution. Colorectal Dis 2007; 9:266.
  40. Fischer JE. A cautionary note: the use of vacuum-assisted closure systems in the treatment of gastrointestinal cutaneous fistula may be associated with higher mortality from subsequent fistula development. Am J Surg 2008; 196:1.
  41. Jamshidi R, Schecter WP. Biological dressings for the management of enteric fistulas in the open abdomen: a preliminary report. Arch Surg 2007; 142:793.
  42. Marinis A, Gkiokas G, Argyra E, et al. "Enteroatmospheric fistulae"--gastrointestinal openings in the open abdomen: a review and recent proposal of a surgical technique. Scand J Surg 2013; 102:61.
  43. Sarfeh IJ, Jakowatz JG. Surgical treatment of enteric 'bud' fistulas in contaminated wounds. A riskless extraperitoneal method using split-thickness skin grafts. Arch Surg 1992; 127:1027.
  44. McIntyre PB, Ritchie JK, Hawley PR, et al. Management of enterocutaneous fistulas: a review of 132 cases. Br J Surg 1984; 71:293.
  45. Girard S, Sideman M, Spain DA. A novel approach to the problem of intestinal fistulization arising in patients managed with open peritoneal cavities. Am J Surg 2002; 184:166.
  46. Subramaniam MH, Liscum KR, Hirshberg A. The floating stoma: a new technique for controlling exposed fistulae in abdominal trauma. J Trauma 2002; 53:386.
  47. Campos AC, Andrade DF, Campos GM, et al. A multivariate model to determine prognostic factors in gastrointestinal fistulas. J Am Coll Surg 1999; 188:483.
  48. Fazio VW, Coutsoftides T, Steiger E. Factors influencing the outcome of treatment of small bowel cutaneous fistula. World J Surg 1983; 7:481.
  49. Reber HA, Roberts C, Way LW, Dunphy JE. Management of external gastrointestinal fistulas. Ann Surg 1978; 188:460.
  50. Aguirre A, Fischer JE, Welch CE. The role of surgery and hyperalimentation in therapy of gastrointestinal-cutaneous fistulae. Ann Surg 1974; 180:393.
  51. Prickett D, Montgomery R, Cheadle WG. External fistulas arising from the digestive tract. South Med J 1991; 84:736.
  52. Schein M. What's new in postoperative enterocutaneous fistulas? World J Surg 2008; 32:336.
  53. Visschers RG, van Gemert WG, Winkens B, et al. Guided treatment improves outcome of patients with enterocutaneous fistulas. World J Surg 2012; 36:2341.
  54. Fischer JE, Evenson AR. Gastrointestinal-Cutanous Fistulae. In: Mastery of Surgery, Fifth, Fischer JE, Bland KI (Eds), Lippincott, Philadelphia 2007. Vol 2, p.1401.
  55. Irving M, White R, Tresadern J. Three years' experience with an intestinal failure unit. Ann R Coll Surg Engl 1985; 67:2.
  56. Schein M, Decker GA. Gastrointestinal fistulas associated with large abdominal wall defects: experience with 43 patients. Br J Surg 1990; 77:97.
  57. Sansoni B, Irving M. Small bowel fistulas. World J Surg 1985; 9:897.
  58. Hill GL. Operative strategy in the treatment of enterocutaneous fistulas. World J Surg 1983; 7:495.
  59. Jernigan TW, Fabian TC, Croce MA, et al. Staged management of giant abdominal wall defects: acute and long-term results. Ann Surg 2003; 238:349.
  60. Becker HP, Willms A, Schwab R. Small bowel fistulas and the open abdomen. Scand J Surg 2007; 96:263.
  61. Owen RM, Love TP, Perez SD, et al. Definitive surgical treatment of enterocutaneous fistula: outcomes of a 23-year experience. JAMA Surg 2013; 148:118.
  62. Lynch AC, Delaney CP, Senagore AJ, et al. Clinical outcome and factors predictive of recurrence after enterocutaneous fistula surgery. Ann Surg 2004; 240:825.
  63. Gupta V, Singh SP, Pandey A, Verma R. Study on the use of T-tube for patients with persistent duodenal fistula: is it useful? World J Surg 2013; 37:2542.
  64. Shestak KC, Edington HJ, Johnson RR. The separation of anatomic components technique for the reconstruction of massive midline abdominal wall defects: anatomy, surgical technique, applications, and limitations revisited. Plast Reconstr Surg 2000; 105:731.