Initial Management of Abdominal Fistula
The initial management of abdominal fistula requires control of sepsis through intravenous antibiotics and percutaneous image-guided drainage of any associated abscesses before considering definitive treatment. 1
Assessment and Classification
First, determine the type and characteristics of the abdominal fistula:
- Location and origin: Enterocutaneous, enterovaginal, enterovesical, enteroenteric
- Output volume: Low (<200 mL/day), moderate (200-500 mL/day), high (>500 mL/day)
- Complexity: Simple vs. complex (multiple tracts, associated abscess)
- Anatomical features: Proximal vs. distal location
Step-by-Step Management Algorithm
1. Control of Sepsis
- Administer intravenous antibiotics to control infection 1
- Perform percutaneous image-guided drainage of any associated abscesses 1
- This is preferred over immediate surgical intervention to minimize complications
- Allows for stabilization before definitive management
2. Fluid and Electrolyte Management
- Correct fluid and electrolyte imbalances, especially in high-output fistulae
- Monitor and replace electrolytes, particularly in high-output fistulae
3. Nutritional Support
- For distal (low ileal or colonic) fistulae with low output: Enteral nutrition can be provided 1
- For proximal fistulae and/or high-output fistulae: Partial or total parenteral nutrition is recommended 1
- Monitor for refeeding syndrome in malnourished patients 1
4. Wound Care and Fistula Effluent Management
- Isolate fistula effluent to protect surrounding skin and promote wound healing 1
- Consider negative pressure wound therapy (NPWT) for effluent isolation and wound healing 1
- Do not apply NPWT directly on exposed bowel
- Separate the wound into compartments to facilitate collection of fistula output
5. Medical Therapy Considerations
- For fistulae associated with Crohn's disease:
- Anti-TNF therapy may be beneficial but should only be started after abscesses have been treated with antibiotics and drainage 1
- Immunomodulators may be considered for maintenance therapy
6. Timing of Surgical Intervention
- Elective surgery is preferable to emergency procedures 1
- Delay definitive surgical management until:
- Sepsis is controlled
- Nutritional status is optimized
- Patient is hemodynamically stable
- Typically 2-4 weeks after successful percutaneous drainage 1
Special Considerations
For High-Output Fistulae
- These usually require surgical intervention for definitive management 1
- More aggressive nutritional support and fluid management are needed
For Low-Output Fistulae
- May be controlled with immunomodulator and biological therapy in Crohn's disease 1
- Conservative management may be successful in selected cases
For Enterocutaneous Fistulae
- Conservative approaches with anti-TNF therapy may lead to closure in some patients 1
- Complexity (multiple tracts) and associated stenosis reduce healing rates with medical therapy 1
Pitfalls to Avoid
- Avoid immediate resection in the setting of acute abdominal abscess 1
- Do not start anti-TNF therapy before controlling abscesses with antibiotics and drainage 1
- Avoid direct application of synthetic prosthesis over bowel loops to prevent entero-atmospheric fistula 1
- Do not apply NPWT directly on viscera 1
- Avoid emergency surgery when possible, as it increases risk of complications, stoma formation, and mortality 1
When to Consider Multidisciplinary Approach
All patients with abdominal fistulae should be managed by a multidisciplinary team including:
- Gastroenterologist
- Surgeon
- Interventional radiologist
- Dietitian
- Wound care specialist
This approach is essential due to the complexity of management and the need for coordinated care to optimize outcomes and reduce mortality 1.