Documenti di Didattica
Documenti di Professioni
Documenti di Cultura
CUTANEOUS
FISTULA
DR.KASHINDRA SINGH
MEDICAL OFFICER,BMC.
Objectives
• Introduction
• Classification
• Etiology
• Prevention
• Management
Introduction
4> Iatrogenic :
- Intra-abdominal abscess
cancer, or IBD
5> Inflammation, Irradiation or Tumour :
• Fever
• Abdominal pain
etiology
nutritional status
malnutrition
sepsis
• Stabilization
• Sepsis control
• Skin care
• Nutrition
• Anatomy identification
• Plan to deal with the fistula
STABILIZATION
• In 24 to 48 hours.
control of infection
• Nutrition can be parenteral or enteral route, based on the anatomy of the fistula.
• Its advisable to provide at least a part of the daily nutritional requirement through
enteral route.(adequate is 25%).
• Nutrition via the enteral route helps in maintaining the intestinal mucosal barrier,
more efficacious delivery of nutrients, stimulating hepatic protein synthesis.
• ORS should be given when oral intake is possible.
• TPN is also given in patients who do not tolerate enteral feeds or have
long standing ileus or before fistulous tract is well established.
Nutrition contd…
Control of sepsis and fistula Effluent
PHARMACOLOGICAL SUPPORT
• Somatostatin analogue Octreotide-100 – 250 mcg TDS reduces fistula output by 40 – 60% by the
end of 24 hrs.
• Octreotide and TPN seem to have a synergistic effect on reduction of effluent volume and
improvement in fistula closure rates.
• Proton-pump inhibitors and H2 receptor antagonists also help reduce fistula output especially in
proximal fistulas.
• Oral dye / Charcoal – shows presence or absence, but not its location, cause or anatomy.
• Fistulography- length & width of the fistula, anatomical location, the presence of any
distal obstructions
• CT Scan- oral and IV- highly recommended for duodenal & pancreatic fistula.
• Surgery between 10 days and 6 weeks post-op will encounter the worst
adhesions.
• However if primary anastomosis is not possible, then both the proximal and
• staged procedure is performed after the infection and inflammation subsides to re-
establish GI continuity and reconstruction of the affected structure after 10 weeks.
Conclusion
skin.
• Majority of the ECF are due to iatrogenic causes (70-85%). Others include
trauma, congenital causes. Spontaneous ECF may arise due to Crohn’s disease.
• Local wound care by application of ostomy bag and pastes are essential.
• ECF with large abdominal defects may require VAC devices/ biologic
mesh SSG to help close the defect.
References …..