What is an Enterocutaneous Fistula?
An enterocutaneous fistula (ECF) is an abnormal pathological connection between the gastrointestinal tract and the skin, allowing intestinal contents to drain externally through the abdominal wall. 1, 2
Definition and Anatomical Description
ECFs represent aberrant communications that connect epithelial structures of the bowel to the cutaneous surface, creating a channel through which intestinal effluent can escape 1, 3
The term "enterocutaneous" specifically describes fistulas connecting the intestine (entero-) to the skin (cutaneous), distinguishing them from other fistula types such as enteroenteric (bowel-to-bowel), enterocolic (small bowel-to-colon), or enterovesical (bowel-to-bladder) 1
A related variant is the enteroatmospheric fistula (EAF), which represents a connection between the gastrointestinal tract and the atmosphere in the setting of an open abdomen 3
Classification by Output Volume
ECFs are best classified based on their daily output volume, which has critical implications for management 4, 5:
Etiology and Associated Conditions
The majority of ECFs occur as complications of abdominal surgery, representing the primary cause of postoperative fistula development 2, 7
ECFs typically communicate with segments of active intestinal inflammation and are frequently associated with other complications including intra-abdominal abscesses, luminal strictures, or surgical anastomoses 4, 5
A substantial proportion (approximately 50%) occur in association with inflammatory bowel disease, particularly Crohn's disease 7
Spontaneous ECFs can develop in patients with cancer, inflammatory bowel disease, diverticulitis, appendicitis, or as a consequence of radiotherapy or trauma 2
Clinical Significance and Prognosis
ECFs are associated with high morbidity and mortality rates due to fluid and electrolyte disturbances, sepsis, and malnutrition 2, 7, 6
Up to 70% of patients with ECFs have malnutrition, which is a significant prognostic factor for spontaneous fistula closure 5, 6
The spontaneous healing rate is low (approximately 20%), with most patients requiring definitive surgical intervention 7
Increasing complexity of the fistula (multiple tracts, associated strictures, or abscesses) is associated with adverse outcomes including increased mortality 4, 8
Historical mortality rates have decreased dramatically from 44% in 1960 to 21% in 1970 to approximately 3-11% in modern series, reflecting improvements in fluid resuscitation, sepsis control, nutritional support, and wound care 3, 7