internal fistula of bowel

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