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Cheyenne Tate-Surgery-Mrs. Christine Valentino, MS, RD, LD

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Fistulas

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Fistula -

An abnormal connection between

organs

Enterovesicular

Enteroenteric

Enterocutaneous

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.

Naming

Name based on participating anatomic components

Internal

External

GI

tract

GI

tract

internal organ peritoneal space

retroperitoneal space

thorax blood vessel

Skin

(more common post-op)

Classifications

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Etiology

Inflammation (Crohn disease, diverticular disease)

Neoplasia (colorectal cancer)

Trauma (penetrating injury)

Infection (tuberculosis)

Iatrogenic (postirradiation,

obstetric, postoperative)

Condition of gut wall

Primary (type 1)

Disease affecting gut wall

Usually requires resection of diseased segment

Secondary (type 2)

Occurs after injury to otherwise normal gut

May close spontaneously with conservative management

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Antibiotic

z Antibiotic Biologic therapies Immunosuppressant General Treatment ▪ Enteral feed ▪ No solid food = less

Biologic therapies

Immunosuppressant

z Antibiotic Biologic therapies Immunosuppressant General Treatment ▪ Enteral feed ▪ No solid food = less

General Treatment

Enteral feed

No solid food = less stool = healing

Surgical

If healthy part of the intestinemay be able to spare

If fistula in diseased part resection

Non Invasive:

Fibrin glue

Plug

Temporary ileostomy

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z Enterocutaneous ▪ Biggest concern for malnutrition ▪ Usually complications from GI surgery ▪ TPN if

Enterocutaneous

Biggest concern for malnutrition

Usually complications from GI surgery

TPN if high output

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z Enteric Fistulas ▪ Commonly IBD or post- op related ▪ Diet: ▪ NPO- during initial

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 outputEN 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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z Colovesical fistula ▪ Connection between the colon and urinary bladder ▪ Complication of: ▪ diverticulitis,

Colovesical fistula

Connection between the colon and urinary bladder

Complication of:

diverticulitis, cancer, or Crohn's disease

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Symptoms

Pneumaturia

Fecaluria

Suprapubic pain

UTI resemblance

Concern for sepsis

Symptoms/Concerns

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Malnutrition > in enterocutaneous fistulas
Malnutrition > in
enterocutaneous
fistulas
TPN if <60% needs met via EN
TPN if <60%
needs met via
EN

Nutritional Implications

TPN if <60% needs met via EN Nutritional Implications Low output (< 200 mL/24 h) •

Low output (< 200 mL/24 h)

1-1.5 g of protein/kg

30% kcal from lipids

h) • 1-1.5 g of protein/kg • 30% kcal from lipids High output (>500 mL/24 h)

High output (>500 mL/24 h)

REE x 1.5-2

1.5-2.5g protein/kg

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 intakeTPN

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Immediate treatment:

Fluid and electrolyte imbalance

Correction of hypovolemia

Dehydration concern

Nutritional Implications

Post-Surgery

Food intake questionable

Discomfort, bloating, fear

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.