high output fistula

1. High output fistula Ri ???

2. Outline Case report Physiology of bile circulation High output biliary fistula Abdominal bile collection

3. Case Report 72 y/o M, left TKR in 91/9 92/12/1 RUQ pain+ jaundice+ cold sweating 1wk ?NTUH ER Bil=2.59; Echo: GB+CBD stone 12/2 ERCP 1(papillotomy+ lithotripsy) 93/3/30 RUQ pain+ fever+ chill 1wk 4/5 ERCP 2, failed due to papilla Vater stenosis, complicated pancreatitis & BTI

4. 4/8 high fever persist 4/12 sudden onset of abd pain+ rebounding pain+ impending septic shock CT: swelling pancreas Echo: dilated CBD & IHD 4/15 PTCD S/C, U/C: P. aeruginosa

5. 4/26 OP1: cholecystectomy+ choledocholithotomy+ choledochoduodenostomy 5/6 post-OP Cx with bile leakage 5/7 methylene blue intake PO, purplish fluid from RD?NPO 5/10 OP2: jejunostomy for feeding 5/15 OP3: debridement+ abscess drainage? SICU

7. Current problems High output fistula (bile) Infection Poor nutrition Difficult weaning due to metabolic acidosis

8. Case report Physiology of bile circulation High output biliary fistula Abdominal bile collection

9. Bile Content %: Water 97Bile salt 0.7Inorganic salts 0.7bile pigments 0.2fatty acids 0.15lecithin 0.1fat 0.1cholesterol 0.06 500ml/day secreted 80% from liver, 20% from ductule Stimulated by: bile salts formation (major)organic anions

10. Composition: bile v.s. plasma

11. Bile salts 50% cholesterol degradation to bile salts; 0.2-0.4g/d 3.5g recirculate 6-8/day, 20-30% escape Major driving force for bile flow and biliary secretion of chol & lethicin Natural laxatives in colon

12. Bile salts structure

13. Other contents secretin? bile ductular epi? HCO3 Gallbladder: concentrated 10-50X, storage, secret mucus and acidify; evacuation by CCK

14. Enterohepatic circulation

15. Case report Physiology of bile circulation High output biliary fistula Abdominal bile collection

16. Post-choledochostomy acidotic syndrome High-volume biliary output >2L/day Cause: cholodochocutaneous fistula, T-tube drain, PTCD Cx: Hyponatremia, dehydration, hypotension, oliguria, metabolic acidosis Tx: IVF, e- supply, bile refeed, gastric aspiration, internal drainage

17. Bile loss: 1.3-7.7 L/day, almost right after ext. bile drain, persist 2-14 days Incidence 5% (PTCD in malignant biliary obstruction) Mechanism: Unknow, hypercholeretic bile acid in serum, biliary hyperplasia, bacteremia, cholangitis

18. Enterocutaneous fistula(ECF) High output> 0.5L/day Incidence: unclear 80% surgical, 20% spontaneous Prognostic factor: nutrition, sepsis Surgical mortality: 6.5-48%

20. Complications Fluid and e- imbalance: NG, H2R antagonist, PPI Sepsis: most common; due to abscess, 2nd infection of skin, poor nutrition, comorbidity Malnutrition: 55-90% p�t(+); inadequate intake, hypermetabolism, hypoproteinemia, BW loss >10%; alb> 3.5 mortality 0%alb< 2.5 mortality 42%

21. Management Correct fluid and e- (IVF, correct anemia, e- repletion) Minimizing malnutrition Control sepsis (ABx, drain abscess) Better outcome if do within 1-2 days Find out the nature: methylene blue, charcol, water-soluble contrast X-ray, fistulogram, CT

22. TPN indications Inability to obtain enteral access High output fistulas GI intolerance with enteral nutrition Multiple unfavorable factors Not proven well in mortality reduction in ECF, but improve spontaneous closure

23. Effect of TPN Soeters: improve spont closure, but not mortality Ryan: improved mortality and spont closure Torres: mean time interval to healing: TPN 20 days, TPN+SS 14 days, closure rate 83% Ysebaert: TPN+SS, spont closure 83%, duration 11+/-7.9

24. TPN strategy

25. Somatostatin 15 a.a. inhibit GI secretion, hormone, motility?Reduce fistula output >50% on 1st day T1/2=1-3 min? rebound hyper-secretion of GH, insulin, glucagon Inactivated by digestive enzyme

26. Octreotide Synthetic SS analogue T1/2=2hr, rebound hypersecretion(-) Prolong GI transit time, decrease endogenous fluid secretions, increased absorption of water and e- Nubiola-Calonge: ?output in 48h of 70%, ?closure time from 50 to 5-10 days Martineau: ? output 39-94%, closure 6-13 days after giving

27. Adverse effect Cholelithiasis, biliary sludge formation in <2% for < 1m usage, but >50% for > 1y usage Nospecific GI symptoms: more often in acromegaly p�t Infrequent: arrhythmia, hypothyroidism, hypo/hyperglycemia, vomiting, flatulence, abd distension, constipation

28. Clinical usage Start: if 7 days of conservative Tx not ? output Stop: if no output ? in 48h, or no response after 2-3 wk of Tx SS: 250ug/h continuous IF Octreotide: 100ug q8H, sc or IM

29. Conservative failure Operative repair: After 6 wks nutrition support, spont closure doesn�t occurUncontrolled sepsis Home TPN: poor surgical riskavailable support system? quality of life, ? costTPN long term complication

31. Case report Physiology of bile circulation High output biliary fistula Abdominal bile collection

32. Post-cholecystectomy abdominal bile collections 154 in 179 p�t (86%) drain tube(-) Bile peritonitis: bile collection+ abdominal pain and tenderness Bile ascites: bile collection, no S/S Only 21% bile collection has S/S Correct Dx initially 23%

34. Reabsorption of bile collection larger than 4cm was rare and unpredictable

35. Predict factor for serious illness:long-term undrained bile (15.4� 19.1 vs 9.2� 10.7) infected bile (45% vs 7%) Every one with undrained bile was at risk Suspected whenever persistent bloating and anorexia, failure to recover as smoothly as expected

36. Take home messages Fluid & e- supply, infection control, nutrition support are the mainstay to treat high-output fistula TPN can improve spontaneous closure rate, but mortality unproven SS/Octreotide can improve closure time but not spontaneous closure rate

37. Thank you for your attention!!