Enterocutaneous fistula used as fistuloclysis

Husni A

INTRODUCTION ; An enterocutaneous (EC) fistula is referred as a channel between the gut and the
skin. The pathophysiology of fistulae can be explored through various techniques, including the
methylene blue test, fistulography, computed tomography scan, ultrasonography, magnetic
resonance imaging and endoscopy (1) . Malnutrition, related to inadequate nutrient intake, loss of
protein rich gastrointestinal secretion and sepsis are the most common complication of EC fistulas,
nutritional management is widely accepted as an important part of complex treatment of these
patients. Indeed before the development of modern nutritional support techniques, most of these
patients died (2).

CASE REPORT : 14 year old women, came to emergency room RSUP HAM with chief complaint feses
came out from surgical site. It has been suffered 2 months after surgery. Previously the patient came
with pain on whole abdomen, physical examination and laboratory examination indicated diffuse
peritonitis due to hollow organ perforation. Laparatomy finding was perforation at the meckel
diverticel with mated adhesion at abdominal cavity. We tried performing adhesiolisis but failed
because we can not identified the anatomy of intra peritoneal organ. Thus we only performed excision
around perforation site and primary suture. The patient was hospitalized for 7 days then discharged.
Oral feeding was performed, flatus and defaction was found normal. The patient controlled to
pediatric departement and we did wound care until all the suture was removed.

At the emergency room patient came with blood pressure 110/70 mmHg, heart rate 88 x/i, respiratory
rate 20 x/i, temperature 37.8 celcius. VAS score 5, and karnofsky score 50. From physical examination
abdomen was symmetrical, feses came out from surgical site, wound was dehisence, and skin around
the wound was irritated. There was no sign of peritonitis. We hospitalized the patient with diagnose
enterocutaneous fistula and malnutrition. We perfomed fasting and total parenteral nutrition. At the
ward, production of the fistula was more 1000cc / 24 hour. For the skin irritation we gave sucrose
sulfate aluminium topically. We diagnose with high output enterociutaneous fistula.

After conservative managment, the fistula production was still 500-1000 cc / 24 hours. We plan for
surgery of refuctionalization entire bowel, resection the fistula followed with end to end anastomosis
and secure abdominal wall. However the condition of hollow organ and nutrition status of patient was
far from sufficient, otherwise we performed conservative management with installment the folley
catheter 18 F into fistula and give enteral feeding through the tube. After 1 week feeding, patient had
progression, the body weight increased from 30 kg to 32,5 kg and albumin increased from 2.5 to 3.1
gr/gl without iv albumin. So, we continued this nutritional management until the patient condition is
suited for surgery manangement.

Fistuloclysis is defined as the infusion of EN formula via the distal stoma of an ECF with or without
reinfusion of the output from the proximal fistula opening. The technique should only be initiated
after confirmation of the integrity and patency of the small intestine beyond the most distal fistula
opening and in ECFs that are not expected to close spontaneously(1,5). The distal opening of the fistula
can be accessed with a tube or catheter, and EN formula and/or chyme is infused through the opening.
The central idea is to use the small intestine to feed both the gut mucosa and the patient and to
minimize use of PN. Tolerance is assessed by whether any increase in ECF output is manageable in
terms of effluent capture and maintaining hydration and by the ability to deliver adequate nutrition
intake. Because semi-elemental (oligomeric) diets are partially digested, greater nutrient delivery may
be obtained with their use

CONCULSION : However, when faced with the development of an enterocutaneous fistula, early
recognition and correction of initial metabolic disarrangement and sepsis is imperative for long-term
success. Subsequent comprehensive care requires a multidisciplinary team specialized in treatment of
these challenging patients. The use of a standardized approach with initial sepsis and fistula control
followed by appropriate nutritional support are key components in the initial management and
stabilization of the enterocutaneius fistula patient.

KEYWORD : ENTEROCUTANEOUS FISTULA, NUTRITION MANAGMENT,

REFERENCES

1. Chung Yan Tong RD, CNSC 1 , Li Lin Lim MRCP2 , Rebecca A Brody PHD, RD, CNSC3, High output
enterocutaneous fistula: a literature review and a case study. Asia Pac J Clin Nutr 2012;21
(3):464-469
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Nutrition support in GI fistulas. e-SPEN, the European e-Journal of Clinical Nutrition and
Metabolism 4 (2009) e313–e314.
3. Ryan P Dumas1 *, Sarah A Moore1 and Carrie A Sims2. Enterocutaneous Fistula: Evidence-
based Management.
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Enterocutaneous Fistula. What is the evidence?.
5. Vanessa J. Kumpf, PharmD, BCNSP1. ASPEN-FELANPE Clinical Guidelines: Nutrition Support of
Adult Patients With Enterocutaneous Fistul. Journal of Parenteral and Enteral Nutrition
Volume 41 Number 1 January 2017 104–112
6. Joshua I. S. Bleier, M.D.1 and Traci Hedrick, M.D. Metabolic Support of the Enterocutaneous
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7. Best Practice Recommendations for Management of Enterocutaneous Fistulae April, 2009