Metoclopramide Use in Enterocutaneous Fistula
Metoclopramide should NOT be used in the management of enterocutaneous fistula and is explicitly contraindicated in this setting. 1
Why Metoclopramide is Contraindicated
Prokinetic drugs like metoclopramide are generally not used after bowel anastomosis, which is the typical setting where enterocutaneous fistulas develop. 1 The rationale is straightforward:
- Metoclopramide stimulates gastric emptying and small intestinal transit, which would increase fistula output rather than reduce it 1
- The drug enhances acetylcholine release from enteric nerves and strengthens gastrointestinal motility 1
- In a patient with an enterocutaneous fistula, accelerating intestinal transit would worsen fluid and electrolyte losses through the fistula tract 2, 3
Additional Safety Concerns
Beyond the physiological contraindication, metoclopramide carries significant safety risks that led European regulatory authorities to recommend against long-term use:
- Extrapyramidal side effects, especially in children 1
- Potentially irreversible tardive dyskinesia in elderly patients 1
- No evidence of consistent benefit even in gastroparesis, its primary indication 1
- The European Medicines Agency's Committee specifically recommended against long-term metoclopramide use due to these concerns 1
What Should Be Used Instead
For managing high-output enterocutaneous fistulas, the evidence-based approach includes:
First-Line Pharmacotherapy
- Proton pump inhibitors (omeprazole) to reduce gastric acid secretion and decrease fistula output 2, 3, 4
- Loperamide (2-8 mg before food) as an antimotility agent to slow intestinal transit 2, 4
- Codeine phosphate can be added to loperamide for additional output reduction 2, 4
Fluid Management
- Restrict oral hypotonic fluids to maximum 500-1000 ml/day 2, 3
- Provide intravenous normal saline (2-4 liters/day) for fluid resuscitation 2
- Replace electrolytes aggressively, particularly sodium and magnesium 2, 3
Definitive Management
- Anti-TNF therapy (infliximab) for fistulas associated with inflammatory bowel disease, but only after treating any abscesses 1, 2, 5
- Surgical intervention is usually required for high-output fistulas after stabilization and nutritional optimization 2, 3, 5
Common Pitfall to Avoid
The critical error would be using any prokinetic agent (metoclopramide, domperidone, cisapride) in enterocutaneous fistula management, as these drugs work by increasing gastrointestinal motility, which is precisely the opposite of what you need. 1 The goal is to slow transit and reduce output, not accelerate it.