GI Fistulas

Principles and management

Dr. Mahmoud W. Qandeel

Outlines
• Definition
• Causes
• Complications
• Evaluation
• Management

Dr. Mahmoud W. Qandeel

A 57-year-old man underwent a laparoscopic splenectomy or
idiopathic thrombocytopenic purpura (ITP). He subsequently develops
a persistent output of 100 mL daily of amylase-rich fluid from a drain
placed at the time of surgery. All of the following would be expected
to prevent spontaneous resolution of this problem except:

A. Octreotide administration
B. Pancreatic duct stricture
C. Infection
D. Nonabsorbable suture in distal pancreatic duct
E. Epithelialization o the tract
Dr. Mahmoud W. Qandeel
 Definition
• Abnormal communication between two or more hollow organs
or between a hollow organ and the body surface.

• Named according to the sites they connect (e.g.,

enterocutaneous fistula connects the small bowel and skin).

Dr. Mahmoud W. Qandeel

 Causes
• Congenital: as in tracheoesophageal fistula
• Operative: as in anastomotic breakdown
• Inflammation: as in Crohn disease, Diverticulitis
• Malignancy: in which tumor destroys tissue (e.g., sigmoid
cancer invades into the bladder)
• Radiation
• Trauma

Dr. Mahmoud W. Qandeel

Dr. Mahmoud W. Qandeel
 Complications
A. Fluid and electrolyte disturbances
B. Infection/sepsis
C. Malnutrition
D. Skin damage
E. Non healing

Dr. Mahmoud W. Qandeel

 Nonhealing fistula:
• Wide diameter
• Short fistula
• High output >500 cc/day
• Proximal
• FRIENDS

Dr. Mahmoud W. Qandeel

Dr. Mahmoud W. Qandeel
Dr. Mahmoud W. Qandeel
 Evaluation and management
• Determine cause (e.g., diverticulitis or cancer) and volume of
drainage (low output has higher rate of closure) and examine
to determine location.

Dr. Mahmoud W. Qandeel

Steps of management
A. Fluid and electrolyte disturbances
B. Infection/sepsis
C. Malnutrition
D. Inhibit organ secretion
E. Skin care
F. Nonoperative management
G. Operative management
H. Sepsis prevention
Dr. Mahmoud W. Qandeel
 Fluid and electrolyte disturbances
Source Volume Na K Cl HCO3
ml / 24 hr mmol / l mmol / l mmol / l mmol /l
Salivary 1000 10 26 10 30

Stomach 2000 60 10 130 0

Duodenum 100-2000 140 5 80 0

Ileum 3000 140 5 104 30

Colon 100-9000 60 30 40 0

Pancreas 100-800 140 5 75 115

Bile 50-800 145 5 100 35

Dr. Mahmoud W. Qandeel

 Fluid and electrolyte disturbances
1. Stomach: Output is rich in H and Cl , causing hypokalemic metabolic
alkalosis; replace with D5 0.45 saline with K .
2. Pancreatic/biliary: High bicarbonate content; can cause dehydration
and metabolic acidosis; Replace with lactated Ringer with HCO3.
3. Small intestine: Drainage is rich in K and bicarbonate; replace with
lactated Ringer with HCO3
4. Large intestines: Higher potassium loss; Replace with lactated Ringer
with K .

Dr. Mahmoud W. Qandeel

 Infection/sepsis
• CT/magnetic resonance imaging (MRI): can determine
undrained abscesses associated with the fistula in persistent
fever

• Healing: requires appropriate antibiotic and drainage

Dr. Mahmoud W. Qandeel

 Malnutrition
• High caloric needs during infection and either loss of nutrition
or poor absorption require early advent o total parental
nutrition (TPN).

Dr. Mahmoud W. Qandeel

 Inhibit organ secretion
• Use H2 blockers for the stomach
• Use octreotide with the pancreas.

Dr. Mahmoud W. Qandeel

 Skin care
• Output can cause skin excoriation; drains, collection bags, or
surgical diversion are necessary to protect the skin.
• Especially from which site of bowel?

Dr. Mahmoud W. Qandeel

 Nonoperative management
• Bowel rest, TPN, and minimizing drainage can allow fistula to
heal in 1–2 months.

Dr. Mahmoud W. Qandeel

 Operative management
• If nonhealing, then operative repair can be performed in a nonseptic, well-
nourished patient.

1. Fistulogram: First, determine anatomy and exclude distal obstruction with

contrast by mouth, rectum, or into the fistula.
2. Resection: With current management, the fistula tract and affected bowel
are resected with anastomosis to restore bowel continuity.
3. Mortality: Current management has lowered the mortality rate to 5%–15%.

Dr. Mahmoud W. Qandeel

 Sepsis prevention
• Enteric and colonic fistulas are complications after trauma,
surgery, diverticulitis, cancer, infammatory bowel disease, and
radiation warranting a mortality rate o 6%–33% mostly due to
sepsis.

• Initial management depends on hydration, nutritional support,

and octreotide to decrease output and drainage of abscesses,
with repair o 25%–75% of fistulas at 3 months.

Dr. Mahmoud W. Qandeel

65 year old male has an enterocutaneous fistula originating
from the jejunum , suffered from inflammatory bowel disease ,
which of the following would be the most appropriate
replacement of his losses ? (4/2017)

A . DW5%
B . N/S 3%
C . Ringer lactate
D . 0.9% sodium chloride
E . 6% sodium bicarbonate solution

Dr. Mahmoud W. Qandeel

65 year old male has an enterocutaneous fistula originating
from the jejunum , suffered from inflammatory bowel disease ,
which of the following would be the most appropriate
replacement of his losses ? (4/2017)

A . DW5%
B . N/S 3%
C . Ringer lactate
D . 0.9% sodium chloride
E . 6% sodium bicarbonate solution

Dr. Mahmoud W. Qandeel

All of the following fistulas are unlikely to close spontaneously
except ? (4/2017)

A . Fistulas secondary to malignancy .

B . Fistulas due to Crohn disease .
C . Fistulas with epithelized track .
D . Fistulas with long track .
E . Fistulas with foreign bodies .

Dr. Mahmoud W. Qandeel

All of the following fistulas are unlikely to close spontaneously
except ? (4/2017)

A . Fistulas secondary to malignancy .

B . Fistulas due to Crohn disease .
C . Fistulas with epithelized track .
D . Fistulas with long track .
E . Fistulas with foreign bodies .

Dr. Mahmoud W. Qandeel

A 57-year-old man underwent a laparoscopic splenectomy or
idiopathic thrombocytopenic purpura (ITP). He subsequently develops
a persistent output of 100 mL daily of amylase-rich fluid from a drain
placed at the time of surgery. All of the following would be expected
to prevent spontaneous resolution of this problem except:

A. Octreotide administration
B. Pancreatic duct stricture
C. Infection
D. Nonabsorbable suture in distal pancreatic duct
E. Epithelialization o the tract
Dr. Mahmoud W. Qandeel
A 57-year-old man underwent a laparoscopic splenectomy or
idiopathic thrombocytopenic purpura (ITP). He subsequently develops
a persistent output of 100 mL daily of amylase-rich fluid from a drain
placed at the time of surgery. All of the following would be expected
to prevent spontaneous resolution of this problem except:

A. Octreotide administration
B. Pancreatic duct stricture
C. Infection
D. Nonabsorbable suture in distal pancreatic duct
E. Epithelialization o the tract
Dr. Mahmoud W. Qandeel