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Internal fistula of bowel
Internal fistula of bowel
Dr sumer yadavDr sumer yadav
FISTULA
FISTULA
Abnormal tube like passage from a normal cavity or tube to a free surface or to another cavity result from congenital incomplete closure of parts or from injuries or inflammatory processes
INTERNAL FISTULAINTERNAL FISTULA
Communication between bowel and some other organ or structure in the peritoneal cavity
Entero enteric fistulaEntero enteric fistula
Occurs when small intestine joins with -Another segment of small intestine or colon
Causescrohn's disease (commonest)Colonic diverticulitisCa. colon
Entero enteric fistula cont.Entero enteric fistula cont.
Ilio-cecal fistulas are commonest presentation in crohn's disease due to chronic inflammation of terminal ileum
Jejunum & duodenum involved less frequently
Fistula formation in crohn's disease
Fistula formation in crohn's disease
Serosal cohesion of healthy bowel to diseased segment
↓Gradual internal perforation
↓Penetration of ulcer through newly formed
common wall↓
FISTULA
symptomssymptoms May symptom less / subtle
abnormalities Present with - Diarrhea, Abdominal pain,
Weight loss & Fever These symptoms are not specific
because may be caused by underlying disease itself
Abdominal tenderness, Abdominal mass Intestinal obst.
Diagnosis Diagnosis
Small bowel series Ba. EnemaNot discovered until laprotomy
Management Management Parenteral nutrition Bowel rest Pharma. Therapy 6-MP, Cyclosporine, infliximab, Azathioprine Surgical intervention
Refractory diseaseIntolerance to medication& their side effects
Surgical intervention (cont.)Surgical intervention (cont.) En bloc resection of diseased intestine in continuity
with the fistula tract F/By anastomosis If inflammation / abscess present
proximal diversion / drainage to allow to subside for 6 wks. & anastomosis
Resection confined to involved segment to conserve overall bowel length as excessive resection can cause
Mal absorption orShort gut syndrome
Entero vesical fistulaEntero vesical fistula
Fistula between Ur. Bladder & small / large bowel
causesCrohn's disease (> 50%)Diverticulitis Ca. colonRadiation injury
Entero vesical fistula (cont.)Entero vesical fistula (cont.)
These are narrow long & tortuous Intermittent patency >80% Pts. Presents with urinary symptoms
FecaluriaPneumaturiaDysuriaBladder irritability
In some cases Fulminant Sepsis d/t contamination with intestinal organisms
Entero vesical fistula (cont.)Entero vesical fistula (cont.)
DIAGNOSISBa.Meal or Enema Oral CharcholOral / rectal Indigo cyanineCystoscopy
Bullous oedemaRetrograde cystographyC T Scan / M R Imaging (most accurate)
Entero vesical fistula (cont.)Entero vesical fistula (cont.)
SURGICAL MANAGEMENT In absence of inflammation / obst. / abscess
Resection of diseased intestine + portion of bladder, primary anastomosis of bowel & closure of bladder wall
OtherwiseTransaction, coetaneous diversion of prox. & dist. Segments F/B definitive procedure after 6 wks.
Nephro enteric fistulaNephro enteric fistula Fistula between bowel & upper urinary tract Anatomic proximity is prime determinant for the
affected segment i.e. Duodenum > Jejunum
CausesRenal TB. & Other bact. Infections (sec. to obstructing renal calc.disease eg. stag horn calc.Renal trauma (penetrating / blunt / iatrogenic)Diverticulitis (rare)
Nephro enteric fistula (cont .)
Nephro enteric fistula (cont .)
SYMPTOMS depends on Nature of underlying renal disease Rapidity with which fistula forms Presence of associated conditions
DiverticulitisPeri nephric abscess
Pt. Appears chronically ill & debilitated Presents as chr.UTI (chills &fever)
or FULMINENT SEPSIS
Nephro enteric fistula (cont .)
Nephro enteric fistula (cont .)
Flank pain & tenderness on palpation Fecaluria, Pneumaturia, N & V Watery purulent diarrhea Dehydration & Uremia (advanced disease) Hyperchloremic acidosis
(urine electrolyte re absorption)
Nephro enteric fistula (cont .)
Nephro enteric fistula (cont .)
DIAGNOSIS Oral Charchol / indigo carmine I V Urography
(if involved kidney remains functional) Retrograde pyelography + cinefluorography C T Scan (associated Peri nephric abscess)
Nephro enteric fistula (cont .)
Nephro enteric fistula (cont .)
TREATMENT Correction of Fluid & elect. Imbalance Correction of anemia Broad spectrum AMA. Nutritional support Retrograde placement of Ureteric cath. /
Nephrostomy (obst. Uropathy + functional kidney)
Nephro enteric fistula (cont .)
Nephro enteric fistula (cont .)
Affective kidney has extensive inflammatory changes (chr.granulomatous disease)NEPHRECTOMY & Intestinal resection is Rx of choice
Conservation of involved renal parenchyma fistula before severe renal impairment
(traumatic fistula)
Entero vaginal fistulaEntero vaginal fistula Fistula between bowel & vagina Causes
Post op. complication of Hysterectomycrohn's diseasechr.granulomatous diseaseMalignant tumors
Entero vaginal fistula (cont.)Entero vaginal fistula (cont.)
SYMPTOMS Purulent / feculent vaginal discharge Intermittent gas discharge from vagina Associated intra abd. Sepsis Fever chills & abd. Pain Signs of hypovolemia with electrolyte imbalance
(profuse discharge)
Entero vaginal fistula (cont.)Entero vaginal fistula (cont.)
DIAGNOSIS Speculum examination
Vaginal erosionsIntestinal contents
Contrast studies
Entero vaginal fistula (cont.)Entero vaginal fistula (cont.)
MANAGEMENT Local drainage
SUMP drains thru.vagina to control sepsis &
fistula output ↴Adequate nutritional support + I.V.
alimentation ↴Spontaneous closure
Entero vaginal fistula (cont.)Entero vaginal fistula (cont.)
If fails ↴resection of cuff of vaginal tissue along with fistulawith primary resection anastomosis / delayed
Vaginal defect may left open to allow external drainage of pelvis
Entero uterine fistula, Entero cervical fistula & Entero fallopian fistula
Entero uterine fistula, Entero cervical fistula & Entero fallopian fistula
Rare varieties Cause
Pelvic malignancyUnusual sequel of long standing ectopic pregnancyRadiation to cervical stumpEndometriosisT.B.Salpingitis & L.G.V.
Aorto enteric fistulaAorto enteric fistula Commonest fistula between Arterial tree & small
bowel Causes
Complication of aortic aneurysmPancreatic transplantation
TypesPrimarySecondary
Aorto enteric fistula (cont.)Aorto enteric fistula (cont.)
PRIMARY AORTO ENTERIC FISTULA Rupture of plaque of athreosclerotic aortic
aneurysm into intestine Mycotic / T.B. / traumatic aneurysm rupture into
intestine III part of Duodenum most often involved Jejunum / ileum rare
Aorto enteric fistula (cont.)Aorto enteric fistula (cont.)
SECONDARY AORTO ENTERIC FISTULAPost opp. Complication of
Aorto iliacAorto femoral prosthetic grafts
Proximal aortic anast. (duodenal fistula)Distal iliac anast. (ilial fistula)
Aorto enteric fistula (cont.)Aorto enteric fistula (cont.)
CLINICAL PRESENTATION Direct communication B/W bowel & arterial lumen
Initially bleeding is intermittent & painless (herald / sentinel bleeding)Pt. Presents with Chr. Anaemia + hemetemesis / malena
orMassive G.I.Hemorrhage SHOCK & DEATH
Aorto enteric fistula (cont.)Aorto enteric fistula (cont.)
Para prosthetic enteric fistulaBowel communicates with a Para graft abscess & not directly communicate with aneurysmClinically presents as SEPSIS & Abd. Pain If untreated ultimately results in a directly communicating fistula
Aorto enteric fistula (cont.)Aorto enteric fistula (cont.)
Pathogenesis depends on Mechanical
+infectious factors
Intestine adjacent to aorta Aortic pulsations cause trauma to bowel Fixation of bowel to anastomotic area & / or
leakage of bowel contentsSubsequent infection / enzymatic digestion of
anastomotic area
↓
Suture line disruption
↓
A.E.F.
Aneurysmal degeneration of graft + mechanical erosion of bowel wall
↓
A.E.F.
DIAGNOSIS & MANAGEMENT Herald hemorrhage
G.I.Endoscopy with dist. Duodenum (no biopsy)C.T.Scan– Loss of fatty planes b/w aortic graft & duodenum– False aneurysm– Para aortic fluid / gas collection
Aortography (active hemorrhage / false aneu.)Ba. studies
DIAGNOSIS & MANAGEMENT
When G/C is POOREmergency laprotomyRemoval of prosthesisExtra anatomic by-pass
Gastro colic & gastro jejuno colic fistula
Gastro colic & gastro jejuno colic fistula
Causescrohn's diseaseNSAIDSMalignancy (gastric adeno Ca, lymphoma)Peptic ulcer diseasePer cutaneous gastrostomyMarginal ulceration after G.J.Stomy
Gastro colic & gastro jejuno colic fistula (cont.)
Gastro colic & gastro jejuno colic fistula (cont.)
Pt presents with c/o Diarrhea & malnutritionShort circuiting of food into colonBacterial overgrowth in stomach & small intestine
Diagnosis Abnormal upper & lower G.I.EndoscopyBa. Enema (more suitable)
Gastro colic & gastro jejuno colic fistula (cont.)
Gastro colic & gastro jejuno colic fistula (cont.)
MANAGEMENT Correction of Fluid & elect. Imbalance Correction of anemia Broad spectrum AMA.pre & per operative Nutritional support En bloc resection of fistula Gastric, jejunal & Colonic suture lines separated
by omentum Diversion / by pass procedures
Cholecysto enteric fistulaCholecysto enteric fistula Inflammatory fistula formation due to gall stone
erosion of gall bladder and migration thru its wall into adjacent II part of duodenum results in persistent cholecysto duodenal fistula.
May remain asymptomatic. Symptoms arises due to gall stone ileus with
distal small bowel obst. d/t stones.
Choledocho duodenal fistula
Choledocho duodenal fistula
Diagnosis Pneumobilia
ERCP stent may perforate III part of duodenum if stent migrate outwards from ampulla.
Pancreato gastric fistulaPancreato gastric fistula Proximal migration of stent into gastric antrum
during Pancreatic duct stenting. Diagnosis
Fluoroscopic contrast examination.CT scan with I V contrast.
Gastro duodenal fistulaGastro duodenal fistula Causes
SurgicalEndoscopyInterventional procedure.
Diagnosis Endoscopy FluoroscopyCT scan
Gastro duodenal fistula (cont.)Gastro duodenal fistula (cont.)
TREATMENTRoux -en- Y gastrojejunostomyDuodenojejunostomy