What is the management approach for an enterocutaneous fistula?

Management of Enterocutaneous Fistula

The management of enterocutaneous fistulas requires a multidisciplinary approach with initial focus on controlling sepsis, optimizing nutrition, and managing fluid/electrolyte balance before considering definitive surgical intervention. 1, 2

Initial Assessment and Stabilization

1. Exclude and Treat Other Causes

• Rule out intra-abdominal sepsis, partial obstruction, enteritis, or recurrent disease 1
• Control any infection with appropriate antibiotics and drainage of collections 2
• Do not start anti-TNF therapy until all abscesses have been treated with antibiotics and drainage 2

2. Fluid and Electrolyte Management

• Correct dehydration with intravenous saline while keeping patient NPO for 24-48 hours 1
• For high-output fistulas (>500 ml/day):
  • Reduce oral hypotonic fluids to 500 ml/day 1
  • Provide glucose/saline solution with sodium concentration of at least 90 mmol/l 1
  • Add sodium chloride to liquid feeds to achieve sodium concentration near 100 mmol/l 1

Nutritional Support

For Low Output Distal Fistulas:

• Enteral nutrition (food) can be used for patients with low ileal or colonic fistulas 1, 2
• Oral diet can be maintained if output is <500 ml/day with good control of drainage 3

For High Output or Proximal Fistulas:

• Partial or exclusive parenteral nutrition is recommended for proximal fistulas and/or very high output fistulas 1, 2, 3
• Malnutrition (BMI <20 kg/m²) is an independent risk factor for poor outcomes 1
• Monitor for refeeding syndrome in malnourished patients 1

Medical Management

Medications to Reduce Output

• Loperamide 2-8 mg before food to reduce motility 1
• Consider adding codeine phosphate if additional output reduction is needed 1
• For "secretory" output (>3 L/24 hours), use:
  • H2 antagonists or proton pump inhibitors 1
  • Octreotide if unable to absorb oral drugs 1

Additional Medical Strategies

• Separate solids and liquids (no drinks 30 minutes before/after food) 1
• Consider salt capsules instead of glucose/saline solution 1
• Trial of fludrocortisone if ileum remains 1
• Correct hypomagnesemia with IV magnesium sulfate initially, then oral magnesium oxide 1

Wound and Fistula Care

Fistula Output Management

• For entero-atmospheric fistulas, negative pressure wound therapy (NPWT) can manage and divert output 1
• Consider creating a "floating stoma" by isolating visible fistulae with an ostomy bag 1
• For remote fistulae, consider converting to an enterocutaneous fistula via separate incision 1

Skin Protection

• NPWT can help protect skin from fistula output 1
• Ensure proper containment of drainage to prevent skin breakdown 2

Definitive Management

Medical Therapy for Fistula Closure

• Anti-TNF therapy may be effective for fistula healing, particularly in inflammatory bowel disease 1, 2
• Success rates vary: approximately one-third of patients may achieve fistula healing with anti-TNF therapy 1
• Complexity (multiple tracts) and associated stenosis reduce healing rates with medical therapy 1

Surgical Intervention

• Surgery is indicated for fistulas with:
  • High-volume output
  • Multiple fistula tracts
  • Associated strictures
  • Postoperative fistulae
  • Failed medical management 2
• Approximately 54% of patients with enterocutaneous fistulae require surgery 2
• Surgical options include resection of the bowel segment communicating with the fistula 4
• Optimize nutritional status before surgical correction 1

Special Considerations

Entero-atmospheric Fistulas

• More challenging to manage than standard enterocutaneous fistulas 1
• NPWT is the best available option for managing these complex wounds 1
• Spontaneous closure rates with NPWT vary widely (8-55%) 1

Inflammatory Bowel Disease

• In Crohn's disease, treat active luminal disease if present 2
• Complexity and associated stenosis reduce healing rates with medical therapy 1

By following this structured approach to enterocutaneous fistula management, clinicians can optimize outcomes and reduce the significant morbidity associated with this challenging condition.