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Cheyenne Tate-Surgery-Mrs.

Christine Valentino, MS, RD, LD


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Fistulas
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Enterovesicular

Fistula-
Enteroenteric
An abnormal
connection between
organs Enterocutaneous
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Naming
Name based on participating anatomic components

Internal External

GI internal organ GI
tract peritoneal space tract Skin
retroperitoneal space
thorax
blood vessel (more common post-op)
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Classifications

Etiology Condition of gut wall


Inflammation (Crohn disease, Primary (type 1)
diverticular disease)
Disease affecting gut wall
Neoplasia (colorectal cancer) Usually requires resection of diseased segment
Trauma (penetrating injury) Secondary (type 2)
Infection (tuberculosis) Occurs after injury to otherwise normal gut
Iatrogenic (postirradiation, May close spontaneously with conservative
obstetric, postoperative) management
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General Treatment
Enteral feed
No solid food = less stool = healing

Surgical
Antibiotic
If healthy part of the intestine may be able to spare
If fistula in diseased part resection

Non Invasive:
Biologic therapies Immunosuppressant
Fibrin glue
Plug

Temporary ileostomy
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Enterocutaneous

Biggest concern for malnutrition

Usually complications from GI surgery

TPN if high output


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Enteric Fistulas
Commonly IBD or post- op related

Diet:
NPO- during initial treatment and during source
control
nutrition support after fluid, electrolyte, vitamin
deficits

Low output EN preferred, but can be


impractical TPN
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Enteric Surgery Details

Segmental resection of involved bowel,


anastomosis of remaining bowel
If abdominal wall has insufficient fascia
Biological mesh
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Colovesical fistula

Connection between the colon


and urinary bladder
Complication of:
diverticulitis, cancer, or Crohn's
disease
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Symptoms/Concerns
Symptoms
Pneumaturia

Fecaluria

Suprapubic pain

UTI resemblance

Concern for sepsis


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Nutritional Implications

Malnutrition > in
enterocutaneous Low output (< 200 mL/24 h)
fistulas
1-1.5 g of protein/kg
30% kcal from lipids

High output (>500 mL/24 h)


TPN if <60% REE x 1.5-2
needs met via 1.5-2.5g protein/kg
EN 2x recommended daily allowance of
lipids
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Controlling Output
Conservative treatment is always preferred if spontaneous
healing is possible
Pharmacologically
Antimotility
PPI
Corticosteroids

Nutritionally
Reduced oral intake TPN
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Nutritional Implications

Immediate treatment: Post-Surgery

Fluid and electrolyte imbalance Food intake questionable

Correction of hypovolemia Discomfort, bloating, fear

Dehydration concern Overall gradual increase to normal


depending on patient
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Prognosis
Depends on output, location, health status

Spontaneous closure rate = 5% to 20%


More likely: Intact abdominal wall + TPN
Less likely: distal obstruction, complete anastomotic dehiscence, ongoing
intra-abdominal sepsis, malnourishment, diseased bowel, abscess, Crohn
disease, underlying malignancy, and foreign objects

Successful surgical closure rate = 75% to 85% of cases


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References
Vikram K. Enterocutaneous Fistula. Background, Etiology, Prognosis.
https://emedicine.medscape.com/article/1372132-overview#a2. Published January 10, 2017.
Accessed October 26, 2017.
Lochs, H. et al. ESPEN Guidelines on Enteral Nutrition: Gastroenterology. Clinical Nutrition .
2006;25:260-274. doi:doi:10.1016/j.clnu.2006.01.007.
Fischer JE, Evenson AR. Gastrointestinal-cutaneous fistulae. In: Mastery of Surgery, Fischer JE (Ed),
Lippincott Williams & Wilkins 2007. Copyright 2007 Lippincott Williams &
Wilkins. www.lww.com.
Stein S. Overview of enteric fistulas. Overview of enteric fistulas.
https://www.uptodate.com/contents/overview-of-enteric-fistulas#H21348536. Accessed
October 26, 2017.
Elsevier Point of Care. CLINICAL OVERVIEW Intestinal fistulae. ClinicalKey.
https://www.clinicalkey.com/#!/content/clinical_overview/67-s2.0-c7371444-81f0-43e0-b0fb-
c1a96cf6dd66. Published March 27, 2017. Accessed October 26, 2017.