A 34-year-old male has been in the ICU for almost three weeks and has undergone several laparotomies following complex abdominal trauma. He appears to have nasogastric feed emanating from his dehisced laparotomy wound and has developed a vasopressor requirement.
Give the likely diagnosis, and outline the principles of its management.

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College answer

Enterocutaneous fistula (ECF) with inadequate source control

Or ECF with undrained collection

Or ECF with septic shock

  • Management
    • Fluid and electrolyte
      • Match losses with crystalloid replacement
      • High sodium loss in high output fistulae
      • Supplement magnesium, phosphate and potassium
    • Sepsis management
      • Source control
      • Target antibiotics, antifungal
  • Surgical or percutaneous drainage of associated collections
  • Definitive surgical management may be delayed 
  • Rule out other sources of infection
     
  • Nutrition
    • TPN often required particularly if proximal fistulae
    • Enteral intake may not be possible if < 75cm bowel remaining
    • Trial elemental feed if intolerant or increased output with polymeric feed
    • Role of zinc and vitamin supplement controversial
  • Wound management and effluent control
    • Principle is effective drainage allowing wound healing
    • Ostomy appliance 
    • VAC dressing controversial as may cause harm, but can be very effective in effluent management of high output fistula
  • Reducing fistulae output
    • Reduce enteral intake and/or consider elemental feed
    • Antidiarrheal – loperamide
    • Somatostatin analogues – octreotide
  • Definition of fistulae anatomy
    • Often difficult to define single source
    • Define and/or exclude distal obstruction
    • CT, fistulography etc

Definitive surgery - may be much later

Examiner Comments:

Not well answered. Many candidates described a generic approach to intra-abdominal sepsis without considering the specific issues related to enterocutaneous fistulae.

Discussion

An approach more directly relevant to enterocutaneous fistulae is described by Cohen et al (2016) Lundy & Fischer (2010) and Evenson (2016).

  • Stabilisation where you resuscitate the septic shock
    • Fluid resuscitation should be conservative to prevent intestinal oedema
    • Vasopressor support should be careful to prevent intestinal ischaemia
  • Diagnosis where you confirm the location and extent of the fistula, by:
    • Methylene blue dyed feeds
    • Contrast "fistulogram" using water-soluble contrast and plain films or fluoroscopy (contrsat both rectal and oral)
    • Contrast CT, which has largely surpassed the fistulogram
  • Evaluation for spontaneous resolution where you decide whether this needs to go to theatre urgently, or whether you can sit on it for a month. Apart from imaging and historicla features, this includes
    • Nutritional assessment, incl. prealbumin, transferrin and clinical assessment
    • Attempted early surgery if you think you can't wait for it to get better on its own (and if the patient is likely to survive)
  • Trial of non-operative management if the impression is that surgery can be delayed
  • Management of infectious complications during conservative management:
    • Intra-abdominal faecal contamination initially - managed with broad-spectrum antibiotics (eg. peperacillin/tazobactam) as well as an antifungal if there are risk factors (malignancy, re-laparotomy, long term antibiotics)
    • Abdominal collections after a prolonged course of systemic antibiotics
  • Management of non-infectious complications during conservative management: 
    • Fluid losses particularly of high-output fistulas: strategies to decrease output include
      • avoidance of vac dressings
      • TPN
      • Octreotide, l​​​​​operamide, opiates
      • Diverting proximal stoma
      • Relief of distal bowel obstruction
    • Malnutrition: TPN and vitamin supplementation
    • Gut atrophy: low volume enteral feeds, or enteral nutrition given via the fistula
    • Electrolyte disturbance resulting from high stoma output (management of this depends mainly on vigilant replacement)
    • Skin excoriation due to spills (management of this requires a dedicated stoma service, or plastic surgical input to deal with tissue loss)
  • Definitive surgical management; or, when it becomes clear that this is not an option,
  • Palliative care

References

References

Cohen, Wess A., et al. "The complex surgical abdomen: What the nonsurgeon intensivist needs to know." Journal of intensive care medicine 31.4 (2016): 237-242.

Edmunds Jr, L. Henry, G. M. Williams, and Claude E. Welch. "External fistulas arising from the gastro-intestinal tract." Annals of surgery 152.3 (1960): 445.

Lundy, Jonathan B., and Josef E. Fischer. "Historical perspectives in the care of patients with enterocutaneous fistula." Clinics in colon and rectal surgery 23.3 (2010): 133.

Chapman, Richard, Robert Foran, and J. Englebert Dunphy. "Management of intestinal fistulas." The American Journal of Surgery 108.2 (1964): 157-164.

Evenson, Amy R., and Josef E. Fischer. "Current management of enterocutaneous fistula.Journal of gastrointestinal surgery 10.3 (2006): 455-464.

Gribovskaja-Rupp, Irena, and Genevieve B. Melton. "Enterocutaneous fistula: proven strategies and updates." Clinics in colon and rectal surgery 29.2 (2016): 130.

Hutchins, Robert R., et al. "Relaparotomy for suspected intraperitoneal sepsis after abdominal surgery." World journal of surgery 28.2 (2004): 137-141.

Green, Gemma, et al. "Emergency laparotomy in octogenarians: A 5-year study of morbidity and mortality." World journal of gastrointestinal surgery 5.7 (2013): 216.

Solomkin, Joseph S., et al. "Guidelines for the selection of anti-infective agents for complicated intra-abdominal infections." Clinical Infectious Diseases 37.8 (2003): 997-1005.

Montravers, P., et al. "Emergence of antibiotic-resistant bacteria in cases of peritonitis after intraabdominal surgery affects the efficacy of empirical antimicrobial therapy." Clinical Infectious Diseases 23.3 (1996): 486-494.

Latifi, R., et al. "Enterocutaneous fistulas and a hostile abdomen: reoperative surgical approaches." World journal of surgery 36.3 (2012): 516-523.

Galie, Kathryn L., and Charles B. Whitlow. "Postoperative enterocutaneous fistula: when to reoperate and how to succeed." Clinics in colon and rectal surgery 19.4 (2006): 237.