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An intestinal fistula is a pathological entero-cutaneous junction. It can arise after any surgical intervention in the gastrointestinal tract. Although it is not a common complication, it poses a serious diagnostic and therapeutic challenge. What are the causes and symptoms of an intestinal fistula? How is the treatment going?

Intestinal fistulais a pathological entero-cutaneous junction. A fistula is defined as the abnormal connection of two or more internal organs or an internal organ to the surface of the body. They can arise as a result of pathological processes (eg trauma, infection), but can also be performed deliberately as part of a surgical treatment, so we can often come across the term "intestinal fistula" in the context of an intestinal stoma, which is not entirely correct.

Intestinal fistula-types

Fistulas can be divided into two groups:

  1. internal - pathological connections that do not communicate with the skin
    • ileo-ileal fistulas
    • ileo-colon
    • enteric-bladder
    • gastro-transverse
    • entero-vaginal
    • large intestine to vagina or pleural cavity
  2. external (entero-cutaneous) - connections between the digestive tract and the skin

How is an intestinal fistula formed?

There are three ways to create an intestinal fistula:

  • the disease process initially involves the intestine and then spreads to the surrounding structures
  • a he althy intestine may become infiltrated by the disease process from neighboring organs
  • a large intestine is injured - iatrogenic or unrecognized

The most common causes of an intestinal fistula are:

  • postoperative complications (especially laparotomy with bowel resection due to cancer, release of adhesions, intestinal obstruction) are the most common cause, accounting for 80-85% of fistulas
  • Crohn's disease favors the occurrence of fistulas between intestinal loops, entero-bladder fistulas
  • radiation damage

About 15 percent of all intestinal fistulas are spontaneous (spontaneous) fistulas.

Preoperative factors favoring the formation of fistulas:

  • malnutrition
  • infection
  • emergency surgery in patients with hypotension, ischemia, hypothermia or hypoxia

Prevention of intestinal fistulas

Before the planned surgery, any deficiencies should be corrected. Blood glucose levels, cardiac output volume and morphological parameters are monitored. Most preferably, the albumin level does not exceed 3 g / dl, while the weight loss in the preoperative period (several months) should not be greater than 15% of the initial weight. In the case of coexisting diabetes or anemia, their course should be carefully monitored. Since infections promote the formation of fistulas, a prophylactic dose of intravenous antibiotics is given before surgery. The situation is much more difficult in the case of emergency procedures. The balancing of cardiovascular and respiratory parameters and the technically accurate performance of the procedure are the only prevention of fistula formation. Before the end of the operation and closure of the peritoneal cavity, organs should be checked for possible iatrogenic injuries and their restoration.

Intestinal fistula - symptoms

Symptoms of a fistula typically develop on day 7-10 after surgery. They should be disturbing:

  • bradycardia
  • chills
  • no return of normal peristalsis
  • hematoma in the wound
  • filter the intestinal contents into the wound and maceration of the skin

Then there are complications:

  • water and electrolyte disturbances
  • malnutrition
  • systemic infection with symptoms of multi-organ failure - this is the most common cause of death in patients with intestinal fistula

Intestinal fistula - diagnosis

In order to suspect the existence of an intestinal fistula at all, it is crucial to collect a detailed medical history, taking into account the previous procedures. It is important to evaluate the contents of the tubing after surgery or leakage from a wound. We evaluate its character, color and volume. Gut content or air in the genital tract or bladder suggests a genitourinary fistula. Diagnostic tests that facilitate diagnosis are:

  • biochemical assessment of discharge
  • X-ray of the digestive tract
  • small intestine passage
  • colon contrast infusion
  • USG
  • CT scan
  • MRI (magnetic resonance imaging)

If it is possible, fistulography is performed, i.e. the fistula is visualized with the use of a contrast medium given through the external opening of the fistula to its canal. A bacteriological examination should also be performed for the sake ofhigh risk of infection.

Intestinal fistula - treatment

The primary goal of treatment is to close the fistula and restore the continuity of the gastrointestinal tract. A detailed diagnosis should always be performed to determine the size of the fistula and its location. We compensate for water and electrolyte deficiencies, as well as metabolic and energy deficiencies. Pharmacological treatment may be considered in patients with a small amount of fistula content and no symptoms of infection. In the event of complications, e.g. septic disorders or bleeding, we implement appropriate treatment. Remember to properly care for the skin around the external opening of the fistula to prevent damage and erosions.

The decision to choose conservative or surgical treatment should be made individually.

The most important element of treatment is the early implementation of intensive parenteral and enteral nutrition. As it turns out, parenteral nutrition increases the chances of spontaneous healing of fistulas up to 70% and, at the same time, reduces the mortality rate to 6-20%. Before intensive feeding methods were introduced, the mortality rate was 60-100%.

Factors that decrease the probability of spontaneous healing of a fistula are:

  • complete dissolution of the anastomosis
  • large opening in the intestine
  • difficult passage below the fistula
  • presence of a foreign body
  • increased inflammatory process near the fistula
  • active Crohn's disease
  • radiation enteritis.

If the fistula has not healed spontaneously within 4-6 weeks, and the patient is adequately nourished, general condition has improved, the infection has been cured and the discharge from the fistula has decreased, it is an indication for reoperation. Surgical treatment includes: excision of the intestine with a fistula and temporary simultaneous anastomosis, creation of an intestinal fistula above the existing fistula, production of a decompression fistula above the reconstructed new anastomosis. In addition, laparoscopic methods are also used with good results while reducing complications.

Patients with diagnosed intestinal inflammation - initial conservative treatment with parenteral nutrition seems effective, unfortunately, after restoring enteral nutrition, fistulas tend to recur. For this reason, surgical treatment should be instituted immediately after spontaneous closure of the fistula.

Among patients with intestinal inflammation, those with Crohn's disease constitute a special group. The location of the fistula is important in choosing a treatment. If the lesion affects the affected section of the intestine, spontaneous closure is lowprobable and early resection is indicated. However, in the case of a fistula of a he althy part of the intestine, resection is not necessary, as it may lead to spontaneous closure.

Patients with an intestinal fistula in the course of cancer or after radiotherapy have a low chance of recovery without resection of the diseased intestine.

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Category:

Gastrology