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 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 signs of peritonitis such as abdominal pain, tenderness, and distension. This approach is supported by several key factors:

1. Resection with primary anastomosis:

   • Addresses the source of infection definitively
   • Associated with fewer recurrences compared to simple repair
   • Appropriate for stable patients with localized pathology 1

2. Timing considerations:

   • The 5-day post-CS presentation suggests an iatrogenic injury
   • Early intervention is critical to prevent further peritoneal contamination
   • Delay in surgical intervention beyond 48 hours significantly increases mortality 1

Why Other Options Are Not Recommended

• Colostomy (option A): Not appropriate for small bowel fistula as it does not address the primary pathology and is unnecessarily invasive for this condition 1

• Soft diet only (option C): Conservative management is contraindicated in this case due to:

  • Presence of peritonitis signs (pain, tenderness, distension)
  • Confirmed fistula on imaging
  • Risk of worsening sepsis and increased mortality with delayed intervention 1

• Hemicolectomy (option D): Excessive and inappropriate intervention for small bowel fistula, as the pathology is in the small intestine, not the colon 1

Surgical Approach

The surgical management should follow these steps:

1. Preoperative preparation:

   • Administer appropriate antibiotics (e.g., Piperacillin/tazobactam 4g/0.5g q6h)
   • Correct fluid and electrolyte imbalances
   • Optimize hemodynamic status 1

2. Surgical procedure:

   • Perform exploratory laparoscopy/laparotomy
   • Start assessment from the ileocecal junction and work proximally
   • Complete assessment of the small bowel
   • Resect the affected segment with primary anastomosis
   • Perform thorough peritoneal lavage 1

3. Surgical approach selection:

   • Open approach for hemodynamically unstable patients or those with peritonitis
   • Laparoscopic approach may be considered in hemodynamically stable patients if expertise is available 1

Post-Operative Care

• Monitor for complications:

  • Anastomotic leak
  • Recurrent fistula
  • Short bowel syndrome
  • Wound infection 1

• Continue appropriate antibiotic therapy for 4-7 days based on clinical condition 1

• Monitor for recurrence symptoms, particularly in the first year after surgical management 1

Important Caveats

1. If the patient becomes hemodynamically unstable during surgery or has severe peritoneal contamination, temporary stoma creation may be necessary instead of primary anastomosis 1

2. Delayed diagnosis and treatment beyond 48 hours significantly increases mortality, emphasizing the importance of prompt surgical intervention 1

3. The surgical approach should be tailored based on the patient's hemodynamic status, with open approach preferred for unstable patients 1