From the Guidelines
Enterocutaneous fistulas should be managed with a multidisciplinary approach, focusing on fluid resuscitation, nutritional support, control of sepsis, wound care, and eventual surgical repair, with the goal of optimizing the patient's nutritional status to improve outcomes, as demonstrated by the most recent evidence from 2023 1.
Key Principles of Management
- Initial treatment involves stabilizing the patient with IV fluids, correcting electrolyte imbalances, and administering broad-spectrum antibiotics if infection is present.
- Nutritional support is crucial, preferably through enteral nutrition if possible, or total parenteral nutrition (TPN) for high-output or proximal fistulas, as supported by the 2023 ESPEN guideline on clinical nutrition in inflammatory bowel disease 1.
- Wound care includes protecting the surrounding skin with barrier products and collecting effluent with ostomy appliances.
- Octreotide (100-200 mcg subcutaneously three times daily) may help reduce fistula output.
Importance of Nutritional Support
- Malnutrition with BMI <20 kg/m2 appears as an independent risk factor for fistula formation and impaired healing 1.
- Early nutritional support, independently of the route of administration, decreases the occurrence and severity of fistulas, as demonstrated by studies cited in the 2023 ESPEN guideline 1.
- A dietetic optimization can be proposed with adapted parenteral support, distinguishing fluid and energy/protein requirements.
Role of Surgical Intervention
- Surgical correction is more likely to be successful if the nutritional status has been optimized preoperatively, as highlighted in the 2023 ESPEN guideline 1.
- Surgical intervention is typically delayed 3-6 months to allow inflammation to subside and the patient's nutritional status to improve.
- Factors that impair healing include malnutrition, infection, foreign bodies, radiation damage, inflammatory bowel disease, cancer, and distal obstruction.
Monitoring and Complications
- Patients require close monitoring for complications including sepsis, fluid and electrolyte imbalances, and skin breakdown.
- The management of enterocutaneous fistulas in Crohn's disease is a complex challenge, with recurrence or further complications unless the nutritional state is optimized, as noted in the 2019 British Society of Gastroenterology consensus guidelines on the management of inflammatory bowel disease in adults 1.
From the Research
Definition and Management of Enterocutaneous Fistula
- Enterocutaneous fistula (ECF) is an abnormal connection between the gastrointestinal tract and skin, often resulting from penetrating Crohn's disease, surgery, or other conditions 2, 3.
- Management of ECF requires a multidisciplinary approach, including fluid resuscitation, electrolyte rebalancing, control of sepsis, nutritional support, and wound management 2, 3, 4.
Nutritional Support
- Nutritional support plays a key role in the management and successful closure of ECF, with enteral nutrition (EN) being the preferred method, supplemented by parenteral nutrition if necessary 5.
- Total parenteral nutrition (TPN) may be indicated in some cases, but enteral feeding should be advocated as early as possible to protect the gut mucosal barrier and prevent bacterial translocation 5.
Treatment Outcomes
- Spontaneous closure of ECF is more common in upper GI fistulas, with 74.8% of patients with ECF proximal to the duodenal-jejunal flexure closing without surgery 6.
- Mortality remains high, associated with sepsis, and is higher in patients who are not able to be discharged in the interval between fistula formation and definitive surgery 6.
- Definitive surgery may be necessary in some cases, with a 30-day post-operative mortality rate of 9.8% 6.
Multidisciplinary Approach
- A multidisciplinary approach is required for successful management of ECF, including the skill and support of specialist stoma care nurses for local control of the effluent 4.
- Early recognition and treatment of sepsis, reducing fluid and electrolyte homeostasis, nutrition support, wound management, and a carefully timed surgical procedure are all crucial components of ECF management 2, 3, 4.