Clinical Case Study:

Enterocutaneous Fistula
(ECF)
JA N UA RY 5 , 2 0 1 5
JE N I F ER L A
K E E N E STATE COL L EG E DI E TETI C I N T ERNSHIP 2 0 1 4 - 2015

Outline
Catholic Medical Center
Enterocutaneous Fistulas
Case Study
TPN Review

Catholic Medical Center (CMC)

Bed size: 330

Non-profit
Location: West Side area of
Manchester,
New Hampshire

CMC Role of Clinical Dietitians

Inpatient:
Provide nutrition assessments based on consults, referrals, LOS
Provide nutrition education based on consults, referrals, admission
Provide nutrition updates/recommendations based level of risk
Conduct calorie counts based on patient needs
Conduct weekly meal rounds
Document, document, document

Enterocutaneous Fistula ECF

Prefix: Entero referring to the intestine

Suffix: Cutaneous referring to the skin

Fistula an abnormal or surgically made passage between a
hollow or tubular organ and the body surface, or between
two hollow or tubular organs

ECF: abnormal passage between the bowel and skin.

ECF Background
Complex patients w/ considerable
morbidity and mortality
Major complications:

Fluid and electrolyte imbalance

Malnutrition
Sepsis
Local wound excoriation

Mortality rates dropped from 60%

to less than 10%
Operative mortality < 5 %

ECF Background
Requires multidisciplinary approach
Spontaneous closures is variable depending on
Etiology
Nutritional status
Output of Fistula

ECF Classification
Anatomical Classification: Internal or External
Internal: named after the structures it communicates with
External: gastric, duodenal, jejunal, ileal, or fecal

Physiologic Classification: Based on Output

Low-output fistula ( < 200ml/day)
Usually colonic

Moderate-output fistula ( 200-500ml/day)

High-output fistula ( > 500ml/day)
Increased risk of electrolyte imbalance and malnutrition

ECF External Fistula

Complication usually seen post surgery
on small or large bowel
95% of ECFs were post-op and ileum was
the most common site
Classified by out-put
Low-output fistula ( < 200ml/day)
Moderate-output fistula ( 200-500ml/day)
High-output fistula ( > 500ml/day)
Increased risk of electrolyte imbalance and malnutrition

ECF - Etiology
Post-operative complication (~75%)

Abdominal trauma/spontaneous (~15-25%)

i.e. cancer, irradiation, IBD, infection, etc.

ECF - Trauma
Surgical

Injury/Accidents
Spontaneous causes
Malignancy, radiation, intra-abdominal sepsis, IBD

ECF Postoperative Causes

Disruption of anastomosis

Inadvertent enterotomy
Inadvertent small bowel injury

ECF Pathophysiology
Formed by abnormal connection between GI tract and skin due to
post-op or trauma
Contents of the stomach and/or intestine leak through the skin
Fever
Localized erythema
Increased intra-abdominal pressure
Passage of mucus and blood
Electrolyte imbalance
Malnutrition

Conservative therapy to rest bowel and promote spontaneous

closure

ECF Pathophysiology: FRIEND

Unfavorable factors that prevent closure of fistula
Foreign Body
Radiation
Inflammation/Infection/Inflammatory bowel disease
Epithelialization of the fistula tract
Neoplasm
Distal Obstruction

ECF Spontaneous Closure

Favorable

Not Favorable

Organ

Oropharyngeal, Esophageal,
Duodenal stump, Jejunal, Colonic

Gastric, Lateral duodenal, Ileal

Etiology

Post-op, Appendicitis,
Diverticulitis

Malignancy, IBD

Output

Low/Mod ( < 200 500 ml/day)

High (> 500 ml/day)

Nutritional State

Well nourished

Malnourished

State of Bowel

Healthy adjacent tissue, Intestinal Diseased adjacent bowel, Distal

continuity
obstruction

Fistula Characteristic

Tract > 2 cm
Bowel wall defect < 1 cm2

Tract < 2 cm
Bowel defect > 1 cm2

ECF Sepsis, Electrolyte Imbalance,

Malnutrition
Degree of sepsis depends on state of ECF

Nearly 70% of patients with ECF may have malnutrition

Predominant factors that lead to death

High-output = electrolyte/fluid loss, and malnutrition

ECF Labs
Total leukocyte count increased levels + sepsis = leukocytosis

Serum Na, K, Cl levels electrolyte abnormalities

Complete blood count (CBC) malnutrition
Total Protein malnutrition
Albumin/Pre-albumin malnutrition
Serum transferrin low levels (< 200 mg/dL) = poor healing

Serum C-reactive Protein increased levels = inflammation

ECF Management
Multidisciplinary approach
Conservative Therapy: SSNAP
Stabilization
Sepsis control and Skin/wound management
Nutrition
Anatomy
Plan

Surgery

ECF Conservative Therapy

Duration: variable, few weeks months

Focuses on
Rehydration
Antibiotics
Correction of anemia
Electrolyte repletion
Drainage of abscess
Nutritional support
Skin/wound healing/protection
Control of sepsis

ECF SSNAP: Stabilization

Resuscitation and Stabilization

Accomplished within first 24-48 hours of management

Control of fluid and electrolyte imbalances

Open abdomen is equivalent to large full thickness burn in

terms of fluid loss
Electrolyte replacement

Close monitoring of input and output of fluids

ECF SSNAP: Sepsis/Skin control

Sepsis most common cause of mortality in ECF
patients
Protect skin from corrosive fistula
Manage fistula output
Two common types of dressings:
Creative Bagging
VAC (vacuum assisted closure)

Bogota Bag

VAC

ECF SSNAP: Nutrition

Aim to return malnourished patients to health

Enteral vs TPN
Enteral preferred
Avoids line-related complications (sepsis, thrombosis,
pneumothorax)
Trophic effect on bowel mucosa
Supports immunological, barrier, and hormonal functions of the
gut
High calorie, protein supplements, electrolyte mix

ECF SSNAP: Nutrition contd

TPN may be required due to
High output
Distal obstruction
Ongoing sepsis

High dose of anti-diarrheals and PPI

Codeine
Loperamide

Recommend vitamins w/ minerals, vit C and zinc x 10 days

Monitor po/supplement intake/tolerance (if applicable), wt changes,
meds, labs, GI fxn

ECF SSNAP: Nutrition

Fistula Output

Calorie REQ

Protein REQ

Fluid REQ

Low Output
High Output

30 35kcal/kg/d
40 45kcal/kg/d

1 1.5gm/kg/d
1.5 2.5gm/d

1L/d of electrolyte
solution + <
500ml/d of low
sodium fluid of
choice

ECF SSNAP: Anatomy and Plan

Continually assess the anatomy of fistula via CT or contrast
studies
Plan
Assess likelihood of non-operative closure
Plan therapeutic course
Decide optimal surgical timing

ECF Treatment Phases

Phase

Primary Goals

Time of Course

1.) Recognition and

Stabilization
(S-S-N)

Correction fluid and

w/ in 24-48hrs
electrolyte imbalance,
Drainage of intra-abdominal
abscess, Control of
sepsis/fistula drainage, Ensure
adequate skin care, Aggressive
nutritional support

2.) Investigation (A)

Determine anatomy and

fistula characteristics

7-10d

ECF Treatment Phases contd

Phase
3.) Decision (P)

4.) Definitive Therapy

5.) Healing

Primary Goal
Determine likelihood of
spontaneous closure and
course of therapy
Closure of fistula,
Reestablish GI continuity,
Secure closure of
abdomen
Ensure adequate
nutrition, Transition to
PO intake

Time of Course
4-6 weeks

After 4-6 weeks or

Closure of fistula is
unlikely
5-10d after closure
onward

ECF - Definitive Surgery

Recommend > 6 months post last laparotomy and 3 months post
peritonitis
Signs that adhesions have worsened
Technique:
Adhesiolysis
Resection of fistulating segment
Abdominal wall reconstruction

Case Study: M.C.

76 y/o female admitted w/ abdominal pain r/t to ECF
with increasing output and fever.

Case Study: M.C. Assessment

Client History
76 y/o F retired nurse and lives in a skilled nursing center. Pt has
PTSD and depression due to death of husband. Pt has supportive
daughter in the area, denies tobacco or alcohol use.
Admitted 5x since February, 2014 due to complaints of N/V/D and
abdominal pain. First three admissions due to SBO, last two
admissions due to ECF drainage. Last admission November, 2014.
11/2014: c/o Fever/lethargy, increased ECF output, N/V/D
PMHx includes but not limited to: HTN, Anxiety, PTSD, Depression,
C. Diff, multiple SBO, Diverticulitis, Colectomy, Small bowel
resection, Pneumonia

Case Study: M.C. - Assessment

Client History contd

February beginning September 2014 followed low fiber, lactose free diet
September November 2014 TPN; was being introduced to full liquid diet
causing increased output, fever, weakness, and diarrhea leading to her most
recent admission

Medications:

Vit B Complex
Iron
Lactobacillus Acidophilus
PPI

Zosyn
IVF
Lopressor
Lovenox

Case Study: M.C. Assessment

Anthropometric Measures
Physical Findings
Wt
UBW

63.5kg (139#)
76.6kg (168.7#)

Ht
BMI
% UBW

5 6
21.9
83%

% IBW
Wt Change

106%
- 13kg (- 30#) x 10 months

Case Study: M.C. Assessment

M.C. Wt Trend
80

75

Wt (kg)

70

65

60

55

50
January

February

May

Time Frame
Wt (kg)

UBW: 76.7kg, 17% (-13kg or 130#) Unintentional Wt Loss

September

November

Case Study: M.C. Assessment

Biochemical, Laboratory, and Diagnostic tests
Value

M.C.

Normal Range

Hemoglobin

8.5 g/dL

11.2 15.7 g/dL

Hematocrit

26.5 %

35.0 48.0 %

Sodium

134 mEq/L

134 - 146 mEq/L

Potassium

4.1 mEq/L

3.5 5.1 mEq/L

Chloride

102 mEq/L

92 105 mEq/L

Calcium

7.7 mg/dL

9 11mg/dL

Magnesium

1.6 mEq/L

1.5 2.0 mEq/L

Phosphorous

2.0 mg/dL

2.5 4.9 mg/dL

BUN

37 mg/dL

6 26mg/dL

Creatinine

0.9 mg/dL

0.6 1.1 mg/dL

Glucose

91 mg/dL

65 99 mg/dL

Total Protein

6.0 g/dL

6.4 8.2g/dL

Albumin

1.9 mg/dL

3.4 5.0 mg/dL

Pre-Albumin

4.8 mg/dL

20.0 40.0 mg/dL

Case Study: M.C. Assessment

M.C. Albumin Trend
3

Albumin g/dL

2.5

1.5

1
May

September

Time
Albumin g/dL

Albumin Ref Range: 3.4 5.0 g/dL

November

Case Study: M.C. Assessment

Food/Nutrition Related History
Pt followed a low fiber, lactose free diet w/ Ensure Compete TID w/
meals to ease symptoms of SBO as pt has had hx of SBO since 2012,
however pt still experienced symptoms of N/V/D.
Ensure Complete provided additional 350kcal, 13g protein per 8oz
Pt is experiencing unintentional wt loss (17%)

Pt developed ECF in September s/p multiple SBO resections

In September, Pt was readmitted for ECF and TPN consult was given

Case Study: M.C. Assessment

Food and Nutrition Related History contd

EER: 30 kcal/kg x 65.3 kg = ~ 1960kcal (based on 9/2014 wt)

Protein: 1.0 1.5g/kg x 65.3kg = 65 98g
TPN Order - 12 hr cyclic:
D70: 400ml
AA15: 570ml
L20: 270ml
Sterile H2O qs for total volume 1800ml
Total Yield: 1834kcal, 86gm protein

Case Study: M.C. Assessment

Estimated Nutritional Needs based on 11/2014 Admission

EER: 35 40kcal/kg x 63.5kg = 2200 2540kcal

Protein: 1.5 2.0g/kg x 63.5kg = 95 127g

Case Study: M.C. Nutrition Diagnosis

Physical Examination:
Temperature: 100.7
HR: 99 bpm
RR: 20 bpm
BP: 106/56
Malnourished temporal wasting/generalized muscle loss
GI: abdomen soft, tender, non-distended; however percutaneous drain was
moved 3-4cm showing liquid stool/foul smelling

Pt previous TPN order is not supporting nutritional needs and is

showing signs of dehydration, inflammation, and malnutrition.

Case Study: M.C. Diagnosis

Problem:
Inadequate energy intake NI-1.2
Malnutrition NI-5.2
Inadequate protein-energy intake NI-5.3
Inadequate protein (amino acids) intake NI-5.7.1
Altered nutrition-related laboratory values (pre-albumin) NC-2.2
Unintended weight loss NC-3.2

Case Study: M.C. Diagnosis

Etiology:
Altered GI function NC-1.4
Less than optimal parenteral nutrition infusion NI-2.8

Case Study: M.C. Diagnosis

Signs/Symptoms:
Pre-albumin 4.8 mg/dL
Albumin 1.9 mg/dL
17% unintentional wt loss x 10 months
Temporal wasting
Generalized muscle loss

Case Study: M.C. Diagnosis

PES:

Malnutrition r/t altered GI function AEB 17% unintentional wt loss in

the past 10 months, generalized muscle wasting, pre-albumin level
of 4.8 mg/dL and TPN order not meeting adequate energy-protein
needs.
Altered nutrition-related laboratory values r/t less than optimal
parenteral nutrition infusion AEB pre-albumin 4.8 mg/dL, albumin
1.9mg/dL, and unintentional 17% wt loss x 10 months.

Case Study: M.C. Nutrition Intervention

Recommended TPN Order:

RMR = 2200 2540kcal

Protein = 95 127g
D70 485ml
AA15 635ml
L20 330 ml
Sterile H2O qs for total volume 1950ml, DR = 80ml x 24hr
Yields 2195kcal, 95.25g protein

How to Calculate TPN

Step 1: Calculate RMR, Protein, and Fluid Needs:
EER: 35 40kcal/kg x 63.5kg = 2200 2540kcal
Protein: 1.5 2.0g/kg x 63.5kg = 95 127g
H2O: ~1950ml

Step 2: Calculate AA15

Divide gm of protein / .15 to get 15% AA solution as needed
95gm/.15 = 633ml 635ml

Step 3: Calculate L20

Multiply total calories by .30 to get fat % required
Then divide by 2 to get ml of 20% lipid solution needed (provides 30% total calories as fat)
2200kcal x .30 = 660/2 = 330ml

How to Calculate TPN contd

Step 4: Calculate D70
Take total calories subtract protein and lipid to get total CHO
calories
To calculate protein calories: Multiply AA15 ml x .15 x 4
To calculate lipid calories: Multiply L20 x 2

Take the total CHO calories and divide by .70 to get grams of CHO
Take grams CHO divide by 3.4 kcal/gm to get ml of 70% dextrose
solution
220 (635x.15)4-(330x2) = 1159kcal
1159kcal/.70 = 1655.7gm/3.4 = 487ml 485ml

Case Study: M.C. Nutrition Intervention

Goal for Nutrition Intervention:
Improve wt gain
Improve visceral protein markers
Improve signs of dehydration
Maximize nutrition support through the most appropriate means
Maximize nutrition for healing w/o worsening overall condition

Case Study: M.C. Monitoring and

Evaluation
S/ Pt lives in nursing home and is a retired nurse suffering from PTSD
and depression. Pt was previously 1 week prior advanced to full
liquids diet which was not tolerable. Pt has extensive surgical history
r/t SBO resulting to partial re-sectioning and colectomy.
O/ 76 y/o, widowed. Pt has a fever w/ c/o of weakness and
abdominal pain. Pt has experienced unintentional wt loss within the
last 10 months (-13kg). Ht: 5 6; Wt: 63.5kg (140#); BMI: 21.9; UBW:
83% wt change.

Case Study: M.C. Monitoring and Evaluation

A/ Pt energy needs are based on 35 40kcal/kg x 63.5kg = 2200 2540kcal.
Estimated protein needs are 95 127g. Based on TPN, pt recommended TPN order
is as follows:

D70 485ml
AA15 635ml
L20 330 ml
Sterile H2O qs for total volume 1950ml, DR = 80ml x 24hr
Yields 2195kcal, 95.25g protein

Nutrition Diagnosis:
Malnutrition r/t altered GI function AEB 17% unintentional wt loss in the past 10
months, generalized muscle wasting, pre-albumin level of 4.8 mg/dL and TPN order
not meeting adequate energy-protein needs.
Altered nutrition-related laboratory values r/t less than optimal parenteral nutrition
infusion AEB pre-albumin 4.8 mg/dL, albumin 1.9mg/dL, and unintentional 17% wt
loss x 10 months.

Case Study: M.C. Monitoring and

Evaluation
P/ Pt nutrition prescription for now is TPN. Pt recommended TPN
order:
D70 485ml
AA15 635ml
L20 330 ml
Sterile H2O qs for total volume 1950ml, DR = 80ml x 24hr
Yields 2195kcal, 95.25g protein

Goal is to maximize nutrition support for healing without worsening

overall condition. Will continue to monitor tolerance to TPN, wt
changes, meds, labs, GI fxn and provide additional nutrition
interventions via the most appropriate means.

References
Berry SM, Fischer JE. Classification and pathophysiology of enterocutaneous fistulas. Surg Clin North Am. Oct
1996;76(5):1009-18.
Draus JM Jr, Huss SA, Harty NJ, et al. Enterocutaneous fistula: are treatments improving?. Surgery. Oct
2006;140(4):570-6; discussion 576-8
Ham M, Horton K, Kaunitz J. Fistuloclysis: case report and literature review. Nutr Clin Pract. Oct 2007;22(5):553-7.
Pritts, T., Fischer, D., Discher, J. (2001.) Surgical Treatment: Evidence-Based and Problem Orientated. Postoperative
Enterocutaneous Fistula. Retrieved from http://www.ncbi.nlm.nih.gov/books/NBK6914/
Schecter WP. Management of enterocutaneous fistulas. Surg Clin North Am. Jun 2011;91(3):481-91
Vikram, K. (2014). Enterocutaneous Fistula. Retrieved from http://emedicine.medscape.com/article/1372132overview#aw2aab6c14
Willcutts, K. (2010). Practical Gastroenterology: Nutrition Issues in Gastroenterology. The Art of Fistuloclysis:
Nutrition Management of Enterocutaneous Fistula. (87). Retrieved from
http://www.medicine.virginia.edu/clinical/departments/medicine/divisions/digestive-health/nutrition-supportteam/nutrition-articles/WillcuttsArticle.pdf