What is the management for a patient with an enterocutaneous fistula (abnormal connection between the intestine and skin) experiencing blood clots in the ostomy (surgical creation of an opening in the body) bag?

Blood Clots in Ostomy Bag with Enterocutaneous Fistula

Blood clots in the ostomy bag indicate gastrointestinal bleeding from the fistula tract or adjacent bowel and require immediate assessment for hemodynamic stability, followed by investigation of the bleeding source and treatment of any underlying sepsis or inflammation.

Immediate Assessment and Stabilization

Assess hemodynamic status first - check vital signs, orthostatic changes, and signs of active bleeding to determine if urgent resuscitation is needed 1, 2. Blood clots suggest more than minor oozing and warrant prompt evaluation.

• Initiate aggressive IV fluid resuscitation with normal saline (2-4 L/day) if the patient shows signs of hypovolemia, particularly important given that enterocutaneous fistulae already cause significant fluid losses 1, 2
• Monitor and replace ongoing losses continuously, with special attention to sodium replacement 1
• Check hemoglobin/hematocrit to quantify blood loss and determine transfusion needs

Identify the Bleeding Source

The bleeding likely originates from one of three sources: mucosal inflammation at the fistula tract, erosion into adjacent vessels, or underlying pathology such as abscess or active Crohn's disease 1, 2.

• Examine the fistula site carefully for signs of infection, abscess, or exposed granulation tissue that could be bleeding 3
• Look for signs of sepsis (fever, elevated white count, hemodynamic instability) as intra-abdominal abscesses commonly complicate enterocutaneous fistulae and can erode into vessels 1, 2
• Obtain imaging with MRI as the preferred diagnostic tool to define fistula anatomy, identify associated abscesses, and evaluate for underlying bowel disease 2, 3

Control Sepsis and Infection

Treat any intra-abdominal abscesses immediately with IV antibiotics and radiological drainage - this is critical as untreated sepsis worsens outcomes and increases mortality 1, 2.

• Never initiate anti-TNF therapy before adequate abscess drainage, as this worsens sepsis and increases mortality 1
• Reserve surgical drainage for radiological drainage failures 1
• Avoid immediate surgical resection until the patient is stabilized 2, 3

Local Wound and Fistula Management

Address excessive granulation tissue or friable mucosa at the fistula opening that may be the bleeding source 3.

• Consider topical silver nitrate or high-potency steroids for excessive granulation tissue 3
• Apply zinc oxide-based skin protectants to protect surrounding skin from fistula output 3
• Use negative pressure wound therapy (NPWT) to manage fistula output, protect skin, and potentially help achieve secure ostomy bag adhesion 1, 3
• Clean the peristomal area with mild soap and water; avoid hydrogen peroxide after the first week as it can irritate skin 3

Optimize Nutritional Status

Malnutrition with BMI <20 kg/m² is an independent risk factor for complications and must be addressed 1, 2.

• For distal (low ileal or colonic) fistulae with low output, provide enteral nutrition 1, 2, 3
• For proximal fistulae and/or very high output, use partial or exclusive parenteral nutrition 1, 2, 3
• Early nutritional support decreases fistula occurrence and severity, with up to 70% of fistula patients having malnutrition 1

Medical Therapy Considerations

If the fistula is associated with active Crohn's inflammation, consider anti-TNF therapy only after sepsis control and abscess drainage 1, 2.

• Anti-TNF therapy achieves fistula healing in only one-third of patients, with half experiencing relapse over 3 years 1
• Medical therapy is unlikely to help postoperative fistulae (within 30 days of surgery) and should not delay surgical planning 1, 2
• Consider proton pump inhibitors to reduce gastric acid secretion and decrease fistula output, particularly for proximal fistulae 2, 3

Definitive Management Planning

High-output fistulae (>500 ml/day) require surgery as they cannot be controlled medically 1, 2.

• Fistulae associated with bowel stricture and/or abscess require surgical intervention 1, 2
• Delay surgery for 3-12 months after initial diagnosis or previous laparotomy to allow lysis of fibrous adhesions and improve outcomes 1
• Never operate immediately without completing fluid/electrolyte balance, sepsis control, nutrition optimization, and skin care - this leads to poor outcomes and high mortality 1

Multidisciplinary Approach

All patients with enterocutaneous fistulae must be managed by a multidisciplinary team including gastroenterologist, surgeon, wound care specialist, and dietitian given the complexity and association with adverse outcomes including mortality 1, 2, 3.