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GI FISTULAS

Delve into the world of gastrointestinal fistulas, from their historical references to classification, etiology, prevention, and management strategies. Explore the pathophysiology, clinical features, and phases of stabilization to definitive therapy. Learn about the complexities of this condition and how to approach it effectively.

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GI FISTULAS

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  1. GI FISTULAS Thusharendhu.N 2002 batch

  2. HISTORY • Earliest record-OLD TESTAMENT book of Judges written by SAMUEL b/w 1043bc and 1004bc • CELSUS-surgical repair of colocutaneous fistula

  3. DEFINITION DEFINITION • Fistula is an abnormal communication b/w two epithelialised surfaces

  4. Gastrointestinal fistula • Pathological communication -connects GI tract with skin, internal organs, peritoneal or retroperitoneal space, thorax

  5. TYPES • Oral, pharyngeal & esophageal • Gastric • Duodenal

  6. Small intestinal fistula • Pouch fistula

  7. Colonic fistula • Internal fistula

  8. CLASSIFICATION • Anatomic • Physiologic • Etiologic

  9. Anatomic… • Based on internal/external • anatomic course • Suggests etiology • Prognosticates spontaneous closure • Assists planning operative • timing & approach

  10. Physiologic • Output(ml/day) • Low<200 prognosticates mortality • Moderate assists physician in • 200-500 anticipating & treating • High>500 met.defects

  11. Etiologic Spontaneous (15-25%) Iatrogenic / post operative (75-85%) • prognosticates spontaneous closure • prognosticates mortality

  12. Spontaneous causes(15-25%) Radiation IBD Appendicitis Ischemic bowel Indwelling tubes Diverticular disease

  13. Perforated ulcers Malignancies Intestinal Actinomycosis / TB Trauma

  14. Iatrogenic causes(75-85%) Cancer Operations Operations for IBD Lysis of Adhesions Others…..

  15. Prevention • Sound surgical procedure • Anastomosis in healthy bowel with adequate blood supply • Anastomosis without tension • Mechanical bowel preparation • Antibiotics • Meticulous & precise hemostasis • Abdominal wall closure • Filling of dead space/drainage with suction • Hydration • Nutritional support

  16. Prevention contd… • Nutritional characteristics-increased risk for anastomotic breakdown • wt.loss of 10-15% of BW over 3-4 months • s.albumin conc.<3g/dl • s.trasferrin conc.<220mg/dl • anergy to injected recall antigens • inability to perform usual tasks bz of weakness/easy fatiguability

  17. PATHOPHYSIOLOGY

  18. FLUID ELECTROLYTE IMBALANCE • Defined as abnormalities in s.electrolytes of >48hrs duration & are primarily associated with high output fistulas • Most commonly these disturbances involve K,Na,Mg,PO4,Zn

  19. MALNUTRITION MALNUTRITION • 3 Main contributary factors: • Lack of adequate nutrient intake • Hypercatabolism associated with sepsis • Loss of protein rich,energy requiring secretions from fistula

  20. SEPSIS • Most common complication of enterocutaneous fistula • Most common cause of fistula related death • CT/MRI,Indium scan • Refunctionalisation

  21. MALIGNANCY • Cause of 3-7% of fistulas • Present in 5-35% of patients with fistulas • Accounts for 30-40% of fistula mortality • Rational treatment plan based on known tumor etiology should be done

  22. NATURAL HISTORY Likely to close Unlikely to close • Anatomic oropharyngeal, gastric,ileal, location duodenal,jejunal, lig.of Treitz pancreaticobiliary • Nutritional well nourished malnourished status • Sepsis absent present

  23. Natural history…. Likely to close Unlikely to close • Etiology appendicitis, crohn’s,cancer, diverticulitis, foreign body, post-op radiation • Condition healthy,small disruption,abscess of bowel leak,no abscess distal obstruction • Miscellaneous tract>2cm length epthelialisation, defect<1cm2 foreign body • Transferrin >200mg/dl <200mg/dl

  24. CLINICAL FEATURES • Pain Fever Abdominal pain / tenderness Raised WBC count • External fistulas- Discharge of intestinal contents • Eso.resp. Fistulas: Lung abscess Aspiration pneumonia Empyema

  25. Clinical features….. • Slow unusual recovery. • Abdominal pain/tenderness,fever leucocytosis. • Excessive drainage/abscess formation. • Skin changes around the wound • Presence of enteric contents in the wound within 24-48 hrs.

  26. MANAGEMENT PHASES • Stabilisation • Investigation • Decision • Definitive therapy • Healing

  27. STABILISATION(within 24-48hrs)

  28. STABILISATION • Resuscitation • Drainage of abscess & local control • Nutritional management • Control of sepsis • Nasogastric tubes • Decrease the volume of secretion • Emotional support

  29. RESUSCITATION • Rehydration-usually crystalloid 3-4 Lit. • Correction of anemia to a hematocrit of 35 by transfusion of packed red cells • Oncotic pressure restoration until s.albumin reaches 3mg/dl

  30. Drainage of abscessand local control • Abscess should be drained 24hrs prior to line insertion • Control of fistula drainage by latex catheter/high pressure suction • Karaya seal,ileostomy cement,glycerine,ion exchange resins-keep skin acidic&prevent activation of pancretic enzymes • Stomadhesive

  31. NUTRITIONAL MANAGEMENT • TPN-gastric,duodenal,pancreatic,jejunal • ENTERAL -esophagus, distal ilium, colon • GI tract should be used if possible provide at least portion of nutritional needs of patient

  32. Control of sepsis • Org. are of bowel origin-coliforms,bacteroides,enterococcus • Staph. Involved in intra abdominal sepsis • Percutaneous drainage under CT guidance • Operative therapy

  33. Measures to decrease vol. of secretion H2 antagonists/proton pump inhibitors Decrease gastric secretion Somatostatin / octreotide • Decrease gastric, pancreatic, small intestinal secretions • Increase absorption of water and • Electrolytes from small intestine • Accelerates gastric emptying but decrease motility of rest of GIT

  34. Emotional support • Continued involvement&reassurance • Attention to ambulation&physical therapy

  35. INVESTIGATION(after 7-10 days)

  36. Fistulogram -define anatomy&pathophysiology • CT/MRI-locate collections&stage cancer

  37. EGD/Colonoscopy • Barium enema

  38. Gatsrocolic fistula Enterocolic fistula

  39. DECISION(7-10 days to 4-6 wks)

  40. Goal of therapy- re-establishment of intestinal integrity • Asses the likelihood of spontaneous closure-depends on • underyling cause • presence/absence of sepsis • anatomic location • condition of the bowel • nutritional status

  41. Decision… • No spontaneous closure/ • No signs of imminent closure after 4-5 wks of nutritional support in a sepsis free patient -decide the surgical timing -patient should be prepared for surgery

  42. DEFINITIVE THERAPY • WHEN SPONTANEOUS CLOSURE IS UNLIKELY / AFTER 4-6 WKS • Plan operative approach

  43. Factors unfavourable for spontaneous closure 1.Total anastomotic disruption 2.Strictured bowel/distal obstruction

  44. 3.Fistulas with associated abscesses

  45. 4.Gastric ,lateral duodenal or lig .treitz fistulas 5.Ileal fistulas

  46. 7.Tract<2cm 6.Defect >1cm2

  47. Indications for Surgery 1.Persistent fistula fails to close After 4-6 weeks conservative treatment in a sepsis free patient 2.Uncontrolled sepsis 3.Fistula poorly prognostic for conservative treatment

  48. Pre-op preparation • Meticulous skin care • Control of fistula drainage • Culture of fistula drainage • Intraluminal & iv antibiotics • Discontinuation of enteral nutrition

  49. Continued…. • If receiving parenteral nutrition • -reduce rate to 40 ml/hr just prior to operation • Operation carried out thru a healhty abdominal wall • Abdomen & operative site-anti bacterial solution • Bowel preparation

  50. SURGERY • Extensive resection with meticulous technique & hemostasis • Approach thru a new incision • Dissection from lig. of Treitz to rectum • All adhesions freed

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