Fistulae: A Problem for the Ages Protection Status

by Lydia A Meyers RN, MSN, CWCN

Enterocutaneous Fistulae (ECF) are a major healthcare issue affecting patients, their lives and the healthcare system. ECF are defined as abnormal connections from one organ to another. The most serious condition is formation from an internal organ to the skin. According to an article by Willcutts, Scarano, & Eddins in 2005, 75% to 85% of all fistulas occur 7 to 10 days after surgery. ECF often develop as a result of the patient's medical condition, past radiation treatments in area, and malnutrition of the patient. The names of ECF are related to exit and entrance points. According to Baranoski & Ayello, 2012, the mortality rate for patients with ECF ranges from 12% to 25%. The mortality is the result of sepsis, malnutrition, and dehydration. The ECF patient faces several problems including: cost of supplies, control of exudate and quality of life issues for the patient.

An example of a patient with an ECF: An obese 50 year old male, after having abdominal surgery, developed a fistula. The abdominal surgery was a bowel resection for Inflammatory Bowel Disease (IBD). An ECF can develop as a result of many medical problems including: Crohn's disease or IBD, traumatic abdominal injury, bowel obstruction, malnutrition of the patient, organ tissue weakening, radiation tissue damage, and in large deep pressure ulcers. The formation of ECF is related to inflammation of the organ wall, abscesses or ulcerations.

The patient developed the following signs and symptoms indicating an ECF formation: abdominal pain, tenderness, fever and leukocytosis. With formation of cellulitis, the ECF drainage will start in 24 to 48 hours, according to an article by Willcutts, Scarano, & Eddins, 2005. With the noted signs and symptoms of ECF formation, the team needed to identify and locate the problem area in order to properly medically manage the patient. The location and diagnosis came from several tests, including: Computerized Tomography, MRI, PET scan, and the gold standard, a fistulogram. Fistulograms are completed with the use of contrast medium pushed into the fistulous tract. It should be noted, however, if the contrast is made of a water-soluble fluid, there is a possibility of a false positive result.

A few examples of the most common ECF are: Colocutaneous (colon to skin), rectovaginal (rectum to vagina) and the most familiar is enterocutaneous (small intestine to skin). ECF are further categorized into two types: Type 1 and Type 2 Complex. Type 1 Complex is related to abscesses and multiple organ involvement. Type 2 Complex is related to a deep, open wound. A third consideration is the amount and type of effluent (drainage). Effluent can be low volume, at less than 500ml in 24 hours, or high volume, at greater than 500ml in 24 hours. The effluent also determines the location of the ECF as follows: Clear to light yellow-green with pH of 3.0 is gastric in location; gold to deep green, and viscous, with pH of 7.5 is biliary; and clear and watery with pH 8.3 is pancreatic.

The medical management of ECF patients include: accurately locating the ECF, having nutritional support, controlling sepsis, and assuring patient has fluid and electrolyte support. This increases the chances of spontaneous closure in one third of the cases. Spontaneous closure generally will happen within 6 to 8 weeks. Good nutrition will increase the chances of a spontaneous closure, thereby shortening the patient's hospital stay.

Other medical interventions include: use of fibrin glue, medications, and surgical intervention. Fibrin glue is a combination of fibrinogen and thrombin and is injected into the debrided area. Medications used are: octreotide and somatostatin, which decrease effluent. However, these are not always effective. Surgical intervention is the last alternative.

The loss of the effluent includes loss of important fluids such as: sodium, potassium, magnesium, zinc, protein, digestive enzymes and water. Two things are very important for successful recovery: to nutritionally supplement these patients as soon as possible with a high quality product and to control effluent. This patient was nutritionally supported with TPN and the appliance utilized to control the effluent was difficult to place and expensive. This patient encountered several problems including insurance approval, fitting the appliance correctly and control of infection. Though TPN has been used on many patients, evidence has shown that enteral nutrition works by supporting the GI system and allows discharge from the hospital sooner.

Control of the effluent increased problems for this patient. He faced many problems including: skin breakdown, dehydration, malnutrition, and infection. These are common problems associated with ECF and medical management of the patient. This patient was on TPN (total parental nutrition). Throughout the hospital stay, continuous monitoring included the patient's fluids, electrolytes and nutrition. Several appliances were tried during hospital stay and none were successful for more than 24 hours. The complications of the skin breakdown, i.e. sights and smells, caused a decrease in the patient's self-esteem.

Low output ECF allow for better control. High output ECF and those within an abdominal wound offer the greatest challenge to control. With high output, the pouching systems are often not enough to contain the drainage and skin creases make it difficult to secure the pouches. Pouches come in several different styles and sizes and very often require adaptation to ensure adequate control. In the patient I have described, the use of Negative Pressure Wound Therapy allowed for better control and the patient was able to function without difficulty. Further research of Negative Pressure Wound Therapy would greatly benefit the ECF patient population.

In conclusion, a patient with a non-healing ECF faces a lifetime of decreased quality of life, increased pain and expenses. The exudate is corrosive to the skin, causes odor and can be difficult to keep contained, unlike an ostomy. High output ECF patients often feel unclean, dirty and unhealthy. Many face a lifetime of decreased strength, pain and lack of acceptance by society. This is not a problem to take lightly and needs continued research to find a product that will work correctly and allow the patient to function in the world.

Baranoski, S., & Ayello, E. (2012). Wound Care Essentials 3rd Edition. Philadephia: Wolters Kluwer/ Lippincott Williams & Wilkins.
McCance, K. L. (2010). Pthophysiology The Biologic Basis for Disease in Adults and Children. Maryland Heights: Mosby.
Steinhart, A. H. (2006). Mount Sinai Hospital Chrohn's & Coloitis. Toronto, Ontario, Canada: Robert Rose Inc.
Willcutts, K., Scarano, K., & Eddins, C. W. (2005, November). Ostomies and Fistulas: a Collaborative Approach. Practical Gastroenterology, 63-79.

About the Author
Lydia Meyers RN, MSN, CWCN has been a certified wound care nurse for over 15 years with experience working in home healthcare, extended care facilities, hospice care, acute care, LTAC, and wound clinics. Her nursing philosophy to "heal wounds as quickly as possible" is the guiding force behind her educational pursuits, both as a teacher and a student.

The views and opinions expressed in this blog are solely those of the author, and do not represent the views of WoundSource, Kestrel Health Information, Inc., its affiliates, or subsidiary companies.

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This is a well written partial review. However, the primary objective should be closure of the fistula. On some occasions surgical re-exploration is required. Remember to ask your self: if bowl is involved or even not, was radiated tissue involved, can there be a foreign body in the wound, if radiation was involved, can the radiation bowl be resected and will a flap be required to bring in new non-irradiated tissue to allow healing to take place. Can residual or unrecognized malignancy be the cause? I have not been all inclusive in my comments but surgery often offers quick answers rather than months and years of therapy which never closes these wounds.

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