Large Intestine: Enterocutaneous Fistula (ECF)

General Enteric Fistulas

• *See Large Intestine: General Enteric Fistula

Definitions

• Enterocutaneous Fistula: A Fistula from the Intestine to Skin
  • Most Commonly from the Small Intestine
• Enteroatmospheric Fistula (Exposed Fistula): A Fistula from the Intestine to the Atmosphere with No Overlying Soft Tissue
  • Occurring in the Context of an Open Abdomen

Causes

• Iatrogenic – Most Common (75-85%)
  • Trauma
  • Surgery (Anastomotic Leak/Missed Enterotomy)
  • Erosion of Foreign Material (Graft/Mesh)
• Spontaneous (15-25%)
  • Crohn’s Disease – Most Common Spontaneous Cause
  • Foreign Body
  • Radiation
  • Inflammation
  • Neoplasia
  • Distal Obstruction
  • Diverticulitis
  • Appendicitis

Output Volume

• Low-Output: < 200 cc/Day
• Moderate-Output: 200-500 cc/Day
• High-Output: > 500 cc/Day

Diagnosis

• Clinical Diagnosis
• Delineate Anatomy by CT with PO/IV Contrast
  • Consider Contrast Enema if Suspected Lower GI Tract Etiology
  • Consider Fistulogram with Contrast Through Fistula Tract

Treatment

• Initial Tx: Conservative (Fluid Resuscitation, Nutritional Support & Skin Protection)
  • Drain Obvious Abscesses
  • Nutrition:
    • Enteral Nutrition is Preferred
    • TPN Indications:
      • High-Output
      • Intestinal Discontinuity
      • Obstruction
  • Options to Decrease Output: Loperamide, Octreotide or Cholestyramine
  • 30-35% Close Spontaneously in 5-6 Weeks
  • 50-65% Will Require Surgical Treatment
• If Fails After 5-6 Weeks: Tract Excision & Segmental Bowel Resection
  • Single-Stage Re-Anastomosis
  • Some Advocate Waiting 5-6 Months

Phases of Care

• Fischer Phases of Management
  • Stabilization (24-48 Hours)
  • Investigation (7-10 Days)
  • Decision (1-6 Weeks)
  • Definitive Therapy (4-6 Weeks)
  • Healing (5-10 Days After Closure)
• Fisher Updated Phases of Management
  • Recognition & Stabilization (24 Hours)
  • Recognition & Drainage of Obvious Abscess (24-48 Hours)
  • Nutritional Assessment & Supplementation (24-48 Hours)
  • Spontaneous Closure (< 60 Days)
  • Operation
  • Postoperative Care
  • Maintain Nutrition & Start Rehabilitation