Bowel%20Fistula

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• Bowel Fistula
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• Dr.Saad Al-Qahtani
• Department of surgery
• College of medicine , King Saud University

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• Fistula is a communication between two
  epithelized surfaces.
• Can be categorized according to
• anatomy.
• outpot.
• character of the tract.

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1-Anatomy

• External (enterocutenous or rectovaginal
  fistula).
• Internal (colovesical or enterocolonic fistula
  ).

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• Proximal( upper GI , ass with high output and
  sever symptoms sequalae, poor prognosis).
• Distal ( ileum , colon rectum. Less complication
  , often close non-operatively).

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2-Output

• High output
• more than 500 ml/ day
• Low output
• less than 200 ml/day

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3-Character of the tract.

• Simple ( single tract )
• Complicated .

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Causes

• Most small intestinal fistulas (75-80) occur as
  a complication following surgery for abdominal
  malignancy, inflammatory bowel disease,
  tuberculosis or adhesiolysis.
• The most common surgical causes of fistula
  formation include anastomotic dehiscence after
  bowel resection and injury to the bowel.
• The rest of the small intestinal fistulas
  (20-25) include the spontaneous type seen in
  inflammatory bowel disease, radiation,
  diverticular disease, ischaemia and malignancy.

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Essentials of Diagnosis

• Fever and sepsis.
• Abdominal pain.
• Localized abdominal tenderness.
• External drainage of small bowel contents.
• Dehydration and malnutrition.

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Pathophysiology

• Loss of GI contents.
• -hypovolemia.
• -acid-base electrolytes disturbance.
• Malnutrition.
• Sepsis.

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Assessment

• 1-Contrast radiography
• -most commonly used.
• -fistulogram for mature fistula(7-10dys).
• -oral contrast show the extravastion is good
  for internal fistula distal obstruction.
• -contrast enema for rectal colonic fistula.
• -pyelography cystography in case of urinary
  tract involved.

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• 2. Endoscopy
• Help to know the coexistent dis e.g Peptic
  ulcer, IBD
• 3-CT abdominopelvic
• To evalute presence of abscess.

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Factors preventing spontaneous closure of small
intestine fistulas

• FRIEND
• Foreign body within the fistula tract
• Radiation enteritis
• Infection/Inflammation at the fistula
  origin
• Epithelialization of the fistula tract
• Neoplasm at the fistula origin
• Distal obstruction of the intestine.

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• Management

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First   Restore blood volume and begin
correction of fluids and electrolyte
imbalance.  Drain accessible abscesses.  Control
fistula and measure losses.  Begin nutritional
support.Second   Delineate anatomy of fistulas
by radiographic studies.Third   Maintain
caloric intake of 20003000 kcal or more per day,
depending on status of nutrition and energy
expenditure.  Drain abscesses as they
appear.Fourth   Operate if fistula fails to
close after 2-3 mths.