What is the best course of action for a woman who develops a small bowel fistula after a cesarean section (CS), presenting with abdominal pain, tenderness, and distension?

Management of Small Bowel Fistula After Cesarean Section

Resection with primary anastomosis (option B) is the preferred treatment for a woman with a small bowel fistula after cesarean section presenting with abdominal pain, tenderness, and distension. 1

Rationale for Surgical Management

The World Journal of Emergency Surgery guidelines strongly recommend surgical intervention for small bowel fistula after cesarean section, particularly when the patient presents with peritonitis symptoms as in this case. The patient's presentation 5 days post-CS with abdominal pain, tenderness, and distension, along with imaging confirmation of a small bowel fistula, necessitates prompt surgical intervention 1.

Key considerations supporting this approach:

• The timing of presentation (5 days post-CS) suggests an iatrogenic injury rather than a spontaneous fistula
• Presence of abdominal distension indicates potential bowel obstruction or peritonitis
• Imaging confirmation of small bowel fistula provides a clear diagnosis requiring definitive treatment

Surgical Approach

The recommended surgical approach involves:

1. Exploratory laparotomy/laparoscopy (open approach preferred if peritonitis or hemodynamic instability is present)
2. Complete assessment of the small bowel, starting from the ileocecal junction and working proximally
3. Resection of the affected segment with primary anastomosis
4. Thorough peritoneal lavage
5. Consideration of biopsies of any suspicious tissue 1

Why Other Options Are Not Recommended

• Colostomy (option A): Not appropriate for small bowel fistula management as it doesn't address the primary pathology and is unnecessarily invasive when primary repair is feasible 1
• Soft diet only (option C): Conservative management is contraindicated in this case due to signs of peritonitis (pain, tenderness, distension) and confirmed fistula on imaging. Delay in surgical intervention beyond 48 hours is associated with significantly increased mortality 1
• Hemicolectomy (option D): This is excessive and inappropriate for a small bowel fistula, as it involves removing part of the colon when the pathology is in the small intestine 1

Perioperative Management

• Preoperative: Administer appropriate broad-spectrum antibiotics (e.g., Piperacillin/tazobactam 4g/0.5g q6h or Eravacycline 1 mg/kg q12h for patients with beta-lactam allergy) 1
• Intraoperative: Assess bowel viability thoroughly; if non-viable, mandatory resection is required
• Postoperative: Continue antibiotics for 4-7 days based on clinical condition and monitor for complications such as anastomotic leak, recurrent fistula, short bowel syndrome, and wound infection 1

Monitoring and Follow-up

• Monitor for signs of complications including anastomotic leak (fever, increasing abdominal pain, leukocytosis)
• Watch for recurrence symptoms, particularly in the first year after surgical management
• Consider delayed primary closure in contaminated cases to reduce wound infection risk 1

Important Considerations

• Early intervention is critical to prevent further peritoneal contamination and systemic inflammatory response
• The surgical approach may need to be modified based on intraoperative findings
• In hemodynamically unstable patients or those with severe peritoneal contamination, temporary stoma formation might be considered instead of primary anastomosis, but this doesn't appear to be the case here 1