Enterocutaneous Fistula(ECF) and it's Management

What is Fistula? 

Fistula which can be defined as an abnormal and unusual communication between two epithelialized surfaces. Enterocutaneous fistula (ECF), as the name implies , is an abnormal communication between the GI tract and the skin. Fistula in ano (FIA) also type of ECF is not discussed here because it's management plan is different from that typical Enterocutaneous fistula.

Classification of Enterocutaneous fistulas 

An ECF can be classified as 

1.external fistula

2.internal fistula

Internal fistula is the abnormal communication between the two hollow viscera and it is mostly seen as a complication of surgery. 

based on the output of enterocutaneous fistula, it can be

Low output fistula (<500 mL/day) 

High output fistula (>500 mL/day)

What are the causes of Enterocutaneous Fistulas? 

1. Surgery as a Postoperative complication(e.g due to disruption of anastomosis and Inadvertent enterotomy) 

2. Trauma 

3. Spontaneous which may include 

 Malignancy

 Intra-abdominal sepsis

 IBD (eg, Crohn disease)

 Radiation enteritis with perforation. 

What are the Favorable factors for spontaneous closure of enterocutaneous fistulas? 

Some anatomic factors determine the Spontaneous closure of ECF. Fistulas that have chance of healing may include the followings. 

End fistulas (eg, those  fistulas that arise from duodenal stump leakage after Pyloric gastrectomy). 

Colonic fistulas. 

Jejunal fistulas. 

Continuity maintained fistulas. These allow patients to pass stool. 

Long-tract fistulas. 

Small-defect fistulas. 

What are the Unfavorable factors for spontaneous closure of enterocutaneous fistulas (ECF)

This types of fistulas are associated with adverse factors. They don't Heels spontaneously, for their closure usually surgery intervention is required. The unfavorable factors can be remembered as mnemonic FRIENDS. Every fistula is destined to heal except with FRIENDS

F= Foreign bodies

R = radiations

I = infection/IBD/Inflammation

E=Epithelialization of fistula tract

N= Neoplasm

D= Distal obstruction

S= sepsis. 

Other General poor prognostic factors

These include followings

Diabetes mellitus 

Renal failure

Immunosuppression. 

Extremes of age 

Liver failure 

Steroid history 

Malnutrition 

Carcinoma 

Radiotherapy or chemotherapy

Workup for enterocutaneous fistula. 

Laboratory Studies 

1.Complete blood count (CBC)including WBCs because WBCs may increase if sepsis is present. 

2. Serum Electrolytes e.g Na, K and Cl levels 

3. Serum C-reactive protein (CRP) - which may be elevated  

4. Serum transferrin - if Low levels (< 200 mg/dL) than it's poor predictor of healing. 

Image studies

Fistulography

Typically performed after 7 to 10 days. It may give clues regarding following 

Length of Fistulas tract. 

Extent of the any  bowel wall disruption. 

Presence of any distal obstruction. 

Location of the fistula. 

Water-soluble contrast enema

Different tracks of fistulas can be seen by Water-soluble contrast enema

Computed tomography (CT)

It's useful if there is intra abdominal abscess in cavities

Management of enterocotaneous fistula

The management of enterocotaneous fistula is done by following four steps which may be remembered as 4R

1. Resuscitation. 

This is the initial step in the management of enterocutaneous fistulas which involved fluid therapy plus electrolyte balance. This also involve the normalization of patients vitals

2. Restitution. 

After resuscitation, the patient is build up by SNAP which is

S= sepsis control and skin protection

N= Nutrients which may involve a period of total parental nutrition (TPN).

A= Anatomical assessment

P= plan( definitive plan for surgery)

3. Restoration or Repair. 

In which definitive management e.g surgery is done

4. Rehabilitation. 

This involves the long-term postoperative management including psychological support.

All management can be summarized as follows 

The Management of Enterocutaneous Fistulas(ECF)