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 approach for a woman with 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 resection with primary anastomosis for small bowel fistulas after cesarean section for several important reasons:

• It definitively addresses the source of infection
• It has fewer recurrences compared to simple repair
• It is appropriate for stable patients with localized pathology
• It prevents further peritoneal contamination and systemic inflammatory response 1

The timing of presentation (5 days post-CS) suggests an iatrogenic injury rather than a spontaneous fistula, which further supports the need for surgical intervention rather than conservative management.

Why Other Options Are Not Recommended

• Colostomy (option A): Not appropriate for small bowel fistulas, as the pathology involves the small intestine, not the colon 1
• Soft diet only (option C): Conservative management is contraindicated as it fails to address the source of infection and may lead to worsening peritonitis and sepsis 1
• Hemicolectomy (option D): This is excessive and inappropriate as the pathology is in the small bowel, not the colon 1

Surgical Approach

The surgical management should include:

1. Exploratory laparoscopy/laparotomy starting from the ileocecal junction and working proximally
2. Complete assessment of the small bowel
3. Resection of the affected segment with primary anastomosis
4. Thorough peritoneal lavage
5. Consideration of biopsies of any suspicious tissue 1

An open surgical approach is recommended for patients with peritonitis or hemodynamic instability, while laparoscopic approach may be considered in hemodynamically stable patients if expertise is available.

Perioperative Management

• Preoperative: Administer appropriate antibiotics based on clinical condition
• Recommended regimens: Piperacillin/tazobactam 4g/0.5g q6h or Eravacycline 1 mg/kg q12h for patients with beta-lactam allergy 1
• Duration: Continue antibiotics for 4-7 days based on clinical response

Postoperative Care

Monitor for potential complications:

• Anastomotic leak
• Recurrent fistula
• Short bowel syndrome
• Wound infection

Consider delayed primary closure in contaminated cases and monitor for recurrence symptoms, particularly in the first year after surgical management 1.

Critical Timing Considerations

Early intervention is crucial as delay in surgical intervention beyond 48 hours is associated with significantly increased mortality. The patient's presentation 5 days post-CS with abdominal pain, tenderness, and distension, along with imaging confirmation of small bowel fistula, warrants prompt surgical intervention to prevent further deterioration 1.