What is the management for a post-cesarean section (CS) patient presenting with abdominal pain, tenderness, distension, and a diagnosed small bowel fistula?

Management of Post-Cesarean Section Small Bowel Fistula

Resection with primary anastomosis is the definitive treatment of choice for a post-cesarean section small bowel fistula presenting with abdominal pain, tenderness, and distension. 1

Initial Assessment and Management

• Immediate surgical exploration is indicated due to:

  • Presentation 5 days post-CS with abdominal pain, tenderness, and distension
  • Confirmed small bowel fistula on imaging
  • Potential peritonitis and risk of sepsis

• Pre-operative preparation:

  • Fluid resuscitation to correct dehydration and electrolyte imbalances
  • Broad-spectrum antibiotics to control infection
  • NPO (nil per os) status
  • Nasogastric tube decompression

Surgical Management

Preferred Approach: Resection with Primary Anastomosis

Resection with primary anastomosis (option B) is the optimal treatment because:

• It definitively addresses the source of infection by removing the affected bowel segment 1
• It has fewer recurrences compared to simple repair or conservative management 1
• It allows for thorough peritoneal lavage to clear contamination
• It provides the best chance for complete recovery and reduced hospital stay

The surgical procedure should include:

1. Exploratory laparotomy
2. Complete assessment of the small bowel
3. Resection of the affected segment with primary anastomosis
4. Thorough peritoneal lavage
5. Consideration of temporary abdominal closure if significant contamination exists

Why Other Options Are Not Optimal

• Colostomy (option A): Not appropriate as the fistula involves the small bowel, not the colon. A colostomy would not address the primary pathology.

• Soft diet only (option C): Inadequate for managing an established small bowel fistula with signs of peritonitis. Conservative management alone has a high failure rate in cases with peritoneal contamination and systemic symptoms 2, 1.

• Hemicolectomy (option D): Excessive and inappropriate surgery for a small bowel pathology. This would remove healthy colon tissue without addressing the actual small bowel fistula.

Post-Operative Care

• Early mobilization to prevent complications 2
• Appropriate antibiotic therapy for 4-7 days based on clinical condition 1
• Monitoring for complications:
  • Anastomotic leak
  • Recurrent fistula
  • Wound infection
  • Short bowel syndrome (if extensive resection was required)

Special Considerations

• In hemodynamically unstable patients, damage control surgery with temporary abdominal closure may be considered initially, with definitive repair delayed 2, 1
• Negative pressure wound therapy may be beneficial if the abdomen cannot be closed primarily 2
• If extensive contamination is present, consider temporary diversion with a proximal stoma, though primary anastomosis remains preferred if technically feasible 1

Follow-Up

• Monitor for recurrence symptoms, particularly in the first year after surgical management 1
• Regular assessment of nutritional status and supplementation if needed
• Delayed abdominal wall reconstruction may be necessary if fascial closure was not achieved during the initial surgery

The World Journal of Emergency Surgery guidelines strongly support resection with primary anastomosis as the definitive treatment for small bowel fistulas with signs of peritonitis, making this the most appropriate management strategy for this post-cesarean section patient.