case_study_of_enterocutaneous_fistula.doc

7/21/2019 case_study_of_enterocutaneous_fistula.doc

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Anna C. GramlNUTN 515Prof. Jessie Pavlinac

The Case of the Enterocutaneous FistulaThe patient, Ms. Pickles (fictional name), is a morbidly obese, 42 year old, white (non!ispanic)

woman, who is a nonsmoker and nonalcohol "ser, is edent"lo"s (4 teeth), and wears no dent"res. #he

presented with ri$ht lower %"adrant abdominal pain, na"sea, emesis, abdominal dehiscence, fe&er, and

diaphoresis and was dia$nosed with an enteroc"taneo"s fist"la ('). This st"dy addresses the

pathophysiolo$ical effects, "s"al medical treatments, and n"tritional needs of ', with emphasis on n"tritional

assessment, medical n"trition therapy (M*T) inter&entions, and medical and n"tritional o"tcomes.!ealth care professionals contin"e to be challen$ed in mana$in$ and treatin$ the potentially catastrophic

postoperati&e complication that is ' (+). ' or $astrointestinal fist"la (-) can ca"se serio"s

pathophysiolo$ical effects on the $astrointestinal (-) tract by allowin$ abnormal f"nctions and passa$e of -

contents, incl"din$ di$esti&e fl"id, water, electrolytes, and n"trients from either intestine to intestine, or intestine to

the o"ter s"rface of the skin (2). Medical treatment for ' is $"ided by anatomic, physiolo$ical, and etiolo$ical

criteria (+, ). /natomical criteria are helpf"l to determine the need for s"r$ical clos"re. The physiolo$ical criteria

are "sef"l in plannin$ a conser&ati&e or nonoperati&e treatment. or e0ample, a low fist"la o"tp"t (1 2 ml3day)

is three times more likely to "nder$o spontaneo"s clos"re than a fist"la with a hi$h o"tp"t ( 5 ml3day) (). The

etiolo$y of the fist"la is necessary to anticipate the patient6s pro$ress and the likelihood of spontaneo"s clos"re (+)./n ' can res"lt from almost any intraabdominal proced"re, beca"se the bowel wall is "nintentionally

dama$ed (2, 4, 5). ' is reported to be a complication in 758 to 958 of abdominal operations, likely related to

patient malno"rishment (). -n 25, Ms. Pickles "nderwent a &entral hernia repair in the middle of her abdomen:

the o"tcome was complicated by dehiscence. !er wo"nd s"t"res opened, e0posin$ the abdomen and res"ltin$ in

an intraabdominal infection. o"r years later, she e0perienced a small bowel obstr"ction from a phytobe;oar

(impacted fr"it or &e$etable fibers) from in$estin$ three pickles. / small bowel resection (remo&al of the dama$ed

bowel) was performed, followed by an anastomosis (attachment of the remainin$ intestine to the abdominal wall).

Ms. Pickles< anastomosis r"pt"red in fi&e days, possibly d"e to her "nderlyin$ risk factors of morbid obesity

(=M->) and anemia (2.> $3?). The intraabdominal infection then presented with an abdominal fist"la. / fist"la is

an abnormal comm"nication between two s"rfaces () and, in the case of an ', the bowel and skin. This

infection can e0ist as peritonitis ("ncontained infection) or abscess (contained infection) (>): she s"ffered from the

latter. The s"r$eon "sed an e0ploratory laparoscopy ('0?ap) method to e0plore her abdominal ca&ity. !owe&er,

'0?ap is associated with the risk of inflammation and de&elopin$ fist"las from the edemato"s bowel loops within

the wo"nd (7). Ms. Pickles< ' was a complication of her intraabdominal infection and '0?ap and presented

with fo"r fist"las within the loops of bowel. Maln"trition is present in 558 to @8 of patients with ' and is


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Anna C. Graml--Enterocutaneous Fistula

responsible for +8 to 8 of the morbidity and mortality incidence. Maln"trition in many ' cases is d"e to loss

of proteinrich - secretions, malabsorption, dehydration, inade%"ate n"trient intake, and on$oin$ sepsis with

hypercatabolism (9). /ccordin$ to the s"bAecti&e $lobal assessment $"idelines, "nintentional wei$ht loss of o&er

+8 in the past > months may indicate maln"trition (@): Ms. Pickles e0perienced a +>.+ k$ "nintentional wei$ht

loss or +.>8 o&er > months.Bnce an ' is reco$ni;ed, recent literat"re s"$$ests prioriti;in$ clinical attention first to n"trition,

sepsis control, and wo"nd care to stabili;e the patient for s"r$ical clos"re of the '. Cithin the first ho"rs of

' presence, the dietitian sho"ld inter&ene with a$$ressi&e &ol"me restoration and correction of electrolytes.

orrectin$ electrolytes is accomplished by modifyin$ amo"nts administered &ia intra&eno"s fl"id or TP* and

pro&idin$ ade%"ate fl"id and oral intake. Dol"me restoration is achie&ed by replacin$ the fist"la6s hi$h o"tp"t

losses e&ery fo"r ho"rs, typically with a normal saline sol"tion and potassi"m s"pplementation (El). Bnce

electrolytes and &ol"me are restored and appropriate wo"nd dressin$ is achie&ed, effecti&e n"tritional s"pport is

the ne0t priority (>, +). =aseline n"trition recommendations for 's incl"de 2 kcal3k$3day and .9 $m

protein3k$3day. Protein re%"irements sho"ld be increased to +.5 to 2.5 $m3k$3day with the presence of hi$h

o"tp"t fist"las (++, +2, +, +4, +5).Many st"dies fa&or total parenteral n"trition (TP*) o&er enteral n"trition ('*) beca"se TP* more

effecti&ely addresses maln"trition and is more likely to impro&e the spontaneo"s clos"re rate of the ' (>).

"rther, the /merican Fietetic /ssociation6s (/F/) '&idence /nalysis ?ibrary ('/?) s"pports parenteral n"trition

(P*) in patients with intestinal fail"re res"ltin$ from a bowel obstr"ction or fist"la. #colapio and collea$"es

disco&ered a 7>8 s"r&i&al rate within the first year of recei&in$ P* and a >48 s"r&i&al rate after 5 years (+>).

Ms. Pickles' Nutrition Diagnosis

1)Altered GI function related to multile ECFs as evidenced !" #i$# %stula outut &1'()) ml* andindication to initiate Parenteral nutrition.

(2)+alnutrition related to ersistent sesis and rotein loss t#rou$# GI secretions as evidenced !"

t#e ,GA'#i$# %stula outut &1'()) ml* 1)/ unintentional 0ei$#t loss over mont#s #i$# serum c-reactive rotein &C2P* 3.5 m$4d &reference ran$e 6 ). m$4d* altered electrolytes7 lo0 serumsodium &Na* 188 mE94 &reference ran$e 18:-1:8 mE94* lo0 serum ma$nesium &+$* 1. mE94&reference ran$e 1.(-3.5 mE94* #i$# serum #os#orus &P):* 5.3 m$4d&reference ran$e 8.5-:.(m$4d*a!normal anemia profle: lo0 serum #emo$lo!in &;$!* 11.5 $4d &reference ran$e 13-1$4d* lo0 serum real!umin15 m$4d &reference ran$e 1(-8) m$4d* lo0 serum al!umin of 3.$4 &reference ran$e :.)-:.($4d*.

Ms. Pickles' Assessment

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Anthropometrics: Gpon admit,stands >9inches (2.+>m2) tall: wei$hs ++.5 k$ ([email protected]): >.9 =M-: presents as 278 of idealbody wei$ht (-=C) of >.> k$: ++.5 k$ "s"albody wei$ht (per Ms. Pickles)Diet HistoryH *"mero"s diets in pre&io"s >months *PB (nil per os): clear li%"id: f"ll

li%"id: p"reed: mechanical soft: re$"lardi&erted from peripheral parenteral n"trition(PP*): TP*SGA Guideline Data: Gpon admit,decreased appetite: f"ll li%"id diet in past 2weeks: na"sea, emesis, and diarrhea in past2 weeks: last bowel mo&ement was monthsa$o: c"rrently bed ridden: edent"lo"s (4teeth) with no dent"res. Grade C severemalnutrition

!iochemical Data""/bnormal, n"tritionrelated lab &al"es"pon admitH#a$ Electrolyteslow ser"m *a + m'%3? (reference ran$e+4+4 m'%3?): low M$ +.> m'%3? (reference ran$e +.72.5m'%3?): hi$h ser"m phosphor"s (P4) 5.2 m$3d? (referenceran$e .54.7 m$3d?)#%$ Endocrine panel""hi$h blood $l"cose +@ m$3d? (reference

ran$e 9@@ m$3d?)#c$ &espiratory value""low total carbon dio0ide (2) of 2mmol3? (reference ran$e 2+ mmol3?)#d$ Anemia profile""low ser"m !$b ++.5 $3d? (reference ran$e+2+> $3d?): low ser"m prealb"min of +5 m$3d? (referenceran$e +7 m$3d?): low ser"m alb"min of 2.> $3? (referenceran$e 4.4.7 $3d?): low !ct .98 (reference ran$e >4>8)#e$ Hepatic function en'ymeshi$h blood "rea nitro$en(=G*) 29 m$3d? (reference ran$e >2 m$3d?), hi$h alkalinephosphatase (/?E Phos) >>+ G3? (reference ran$e 42@9 G3?):hi$h aspartate aminotransferase (/#T) 5@ G3? (reference ran$e+54+ G3?): hi$h alanine aminotransferase (/?T)+++G3?(reference ran$e +49 G3?)

Ms. Pickles< abnormal n"tritionrelated lab &al"es in the abo&e chart co"ld be e0plained as followsH#a$/bnormalelectrolyte &al"es co"ld be related to hypoma$nesemia, hyperphosphatemia,

dehydration, mild hypernatremia with hi$h fl"id loss thro"$h the skin (e0cessi&e sweat), and hi$h o"tp"t 's

(9, +7).#%$Th"s, the ele&ated endocrine panel was likely associated with the presence of these hypertonic

effects (++).#c$/ reason for the low respiratoryvalueco"ld be d"e to tachycardia (+7).#d$/ltho"$h the anemia profileis listed as n"tritionrelated, c"rrent e&idence s"$$ests that the anemia

profile may not be an acc"rate marker of n"tritional stat"s, beca"se red"ced plasma proteins, s"ch as

alb"min3prealb"min, reflect an ac"te metabolic deran$ement dri&en by an inflammatory response "s"ally

associated with other comorbidities and "nderlyin$ conditions,e&en when there are ade%"ate ener$y and protein

intakes. Probable reasons for altered anemia &al"es are inflammation, catabolism, and impaired wo"nd3fist"la

healin$ which may infl"ence morbidity and mortality (+9).#a$( #d$( and #e$Chen electrolyteser"m *a and ne$ati&e ac"tephase proteins, s"ch as

alb"min3prealb"min le&els in the anemia profileare low, the hepatic function en'yme =G* is hi$h, fl"id shifts

ca"se sodi"m dil"tion of the cells (+7,+9).#e$ Thehi$h =G* le&el may represent protein maln"trition. !i$h liver function values/#T, /?T, and

/?E Phos co"ld be from li&er dysf"nction or dama$e, or mild transaminitis (m"ltior$an fail"re) (+9).

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#f$The elevated CPma" indicate a s"stemic in kcals and >5.4 $m protein thro"$h

TP*. #tandard electrolytes and additi&es, incl"din$ + m? of an ad"lt m"lti&itamin and one dose of trace

elements, were inf"sed thro"$h TP*. #he was also placed on a p"reed, oral diet "pon admit to help pre&ent

food embeddin$ in the m"ltiple fist"las alon$ with three n"tritionally s"pplemented drinks (=oost Pl"s) daily.Day *: /fter Ms. Pickles< hei$ht was remeas"red at 59 inches (+.47 m2), we recalc"lated her ener$y

and protein needs to be @+2 kcals (2225 kcal3-=C) and +2 $m protein (2.5 $m3-=C), respecti&ely, and

-=C at 4.+ k$ (++, +2, +). Fr. Iobert Martindale ad&anced her diet to mechanical soft and contin"ed the

(three) =oost Pl"ses. ?abs reflected a low ser"m potassi"m (EJ) .2 m'%3? (reference ran$e .45. m'%3?),

an increased, b"t not optimal, M$ of +.7 m'%3?, chronically hi$h P4 5.2 m$3d?, and low calci"m (a) 9. m$3d?

(reference ran$e 9.>+.2 m$3d?). =y the end of Fay 2, we modified the TP* inf"sion to meet new estimated

needs and attempt to correct her electrolyte panel: potassi"m chloride (E-) was increased from 2 to 5

m'%3?, ma$nesi"m s"lfate (M$#4) was increased from 9 to +4 m'%3?, and all the phosphor"s (EPB4) was

remo&ed (+5 to mmol3?). #ince ;inc, ascorbic acid (&itamin ), and seleni"m sho"ld also be increased to

enhance wo"nd healin$ (+2, +5), an additional 5 m$ ;inc, 5 mc$ &itamin , and 2 mc$ seleni"m were

inf"sed thro"$h TP*.Day +: M*T from Fay 2 contin"ed, incl"din$ pre&io"s TP* modifications to maintain electrolytes within

their tar$et ran$e: all labs were corrected to their normal ran$e. *"trition inter&entions were not chan$ed from

Fay 2.Days , to -: There was a TP* holiday beca"se an oral intake test was bein$ $i&en. To e&al"ate her

capability to meet her ener$y and proteinneeds witho"t TP*,a twoday calorie co"nt was ordered and reflected

an oral intake of +47 kcal and 57 $m protein on Fay 4 and 2+9 kcal and + $m of protein by Fay >.

!owe&er, the oral intake test did not s"cceed: her na"sea increased and her fist"la o"tp"t wascopio"s (the

notes did not specify the amo"nt of o"tp"t increase).TP* was th"s res"med beca"se an e0cl"si&e oral diet

co"ld not meet the appropriate ener$yand protein needs d"e to malabsorption. Ms. Pickles< electrolytes

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remained stable thro"$ho"t her oral intake test.

Day .: TP* and mechanical soft diet orders res"med.Day /H Ms. Pickles< electrolyte, endocrine, respiratory and prealb"min labs reached ideal le&els and she

was dischar$ed. !owe&er, alb"min and =G* werelow at 2.7 $3? and 4 m$3d? respecti&ely, and hepatic

f"nction tests contin"ed to be ele&ated. /ltho"$h impro&ements in ne$ati&e ac"tephase proteins, s"ch as

prealb"min and positi&e ac"tephase proteins, s"ch as IP represented an impro&ement of Ms. Pickles< o&erall

clinicalstat"s, they were not appropriate markers of her o&erall nutritionalstat"s (+7, +9).To s"mmari;e, Ms. Pickles was admitted as a se&erely malno"rished patient with n"mero"s physical

and physiolo$ical challen$es. -t was essential for the M*T to promote fist"la healin$ and attain an appropriate

stat"s for a fist"la clos"re operation. #tabili;in$ and impro&in$ n"tritional stat"s was accomplished by reachin$

optimal le&els of key electrolytes thro"$h a$$ressi&ely monitorin$ and adA"stin$ TP* inf"sion rates, while

s"pplyin$ ade%"ate ener$y and protein needs. The diet order ad&anced from p"reed to mechanical soft for

recreational intake and was to be contin"ed at the skilled n"rsin$ facility (#*). #ince it was deemed

impractical to place her solely on an oral diet, her most recent TP* re$imen was to contin"e at the #* where

she wo"ld reside after dischar$e. Ms. Pickles was sched"led for a fist"la clos"re operation three weeks after

dischar$e.

&eferences

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+7(7)H 4444.

2. Ewon #!, Bh K!, Eim !K, Park #K, Park !B. -nter&entional mana$ement of $astrointestinal fist"las. KoreanJ Radiol. 29: @(>)H 54+54@.

. =erry #M, ischer K'. lassification and pathophysiolo$y of enteroc"taneo"s fist"las. Surg Clin North Am.+@@>: 7>H+@++9.

4. alie E?, Chitlow =. Postoperati&e enteroc"taneo"s fist"laH Chen to reoperate and how to s"cceed. ClinColon Rectal Surg. 2>: +@H2724>.

5. ekaA ', #alih" ?, Morina /. Treatment of enteroc"taneo"s fist"la with total parenteral feedin$ in combinationwith octreotideH a case report. Cases Jrnl. 2@: 2H+77.

>. #checter CP, !irshber$ /, han$ F#, !arris !C, *apolitano ?M, Ce0ner #F, F"drick #K. 'nteric fist"lasHPrinciples of mana$ement. J Am Coll Surg. 2@: 2@(4)H4944@.

7. onnolly PT, Te"bner /, ?ees *P, /nderson -F, #cott */, arlson ?. B"tcome of reconstr"cti&e s"r$ery forintestinal fist"la in the open abdomen.Ann Surg. 29: 247H 44444.

9. Lahoor M/, Eomar MK, #till F. *"trition and enteroc"taneo"s fist"las. J Clin Gastroenterol. 2: +H+@524.

@. =a"er K, apra #, er$"son M. Gse of the scored patient$enerated s"bAecti&e $lobal assessment (P#/)as a n"trition assessment tool in patients with cancer. EJCN. 22: 7>H77@795.

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+. Disschers IK, Famink #CMB, Cinkens =, #oeters P=, Dan emert C. Treatment strate$ies in +5consec"ti&e patients with enteroc"taneo"s fist"las. World J Surg. 29: 2H44545.

++. F"drick #K, MaharaA /I, McEel&ey //. /rtificial n"tritional s"pport in patients with $astrointestinal fist"las.World J. Surg. +@@@: 2H5757>.

+2. #techmiller KE, owan ?, ?o$an EM. *"trition s"pport for wo"nd healin$. Support Line. 2@: +(4)H27.

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https://ozone.ohsu.edu/foodandnutritionservices/suggestedguidlines/adultpressureulcerhealingdifficultwounds.pdfhttp://nutritioncaremanual.org/topic.cfm?ncm_toc_id=144839&ncm_heading=Nutrition%20Carehttp://nutritioncaremanual.org/topic.cfm?ncm_toc_id=144839&ncm_heading=Nutrition%20Carehttp://www.adaevidenceanalysislibrary.com/http://www.adaevidenceanalysislibrary.com/https://ozone.ohsu.edu/foodandnutritionservices/suggestedguidlines/adultpressureulcerhealingdifficultwounds.pdfhttp://nutritioncaremanual.org/topic.cfm?ncm_toc_id=144839&ncm_heading=Nutrition%20Carehttp://nutritioncaremanual.org/topic.cfm?ncm_toc_id=144839&ncm_heading=Nutrition%20Carehttp://www.adaevidenceanalysislibrary.com/

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case_study_of_enterocutaneous_fistula.doc