Gastrointestinal Fistulas - Mousa Mashagbah

8/7/2019 Gastrointestinal Fistulas - Mousa Mashagbah

http://slidepdf.com/reader/full/gastrointestinal-fistulas-mousa-mashagbah 1/23



10:43 2

DefinitionDefinition

Fistulas are abnormalcommunications between two

epithelial-lined surfaces.

Gastrointestinal (GI) fistulasrepresent abnormal ductlike

communications between the

gut and another epithelial-lined

surface, such as another organ

system, the skin surface, or

elsewhere along the GI tract

itself.

Fistulas are abnormalcommunications between two

epithelial-lined surfaces.

Gastrointestinal (GI) fistulasrepresent abnormal ductlike

communications between the

gut and another epithelial-lined

surface, such as another organ

system, the skin surface, or

elsewhere along the GI tract

itself.



CLASSIFICATION OF GI FISTULAS

CLASSIFICATION OF GI FISTULAS

GI fistulas can be categorized as

external or cutaneous if they

communicate with the skin surface

or internal if they connect to

another internal organ system or

space, including elsewhere along

the GI tract itself.

Internal GI fistulas can be further

divided into two types: intestinal

and extraintestinal.

Intestinal fistulas refer to a gut-to-

gut connection .

Extraintestinal internal fistulas

imply communication of the GI

tract with another organ system.

GI fistulas can be categorized as

external or cutaneous if they

communicate with the skin surface

or internal if they connect to

another internal organ system or

space, including elsewhere along

the GI tract itself.

Internal GI fistulas can be further

divided into two types: intestinal

and extraintestinal.

Intestinal fistulas refer to a gut-to-

gut connection .

Extraintestinal internal fistulas

imply communication of the GI

tract with another organ system.

10:43 3



CAUSES OF GI FISTULAS (1)CAUSES OF GI FISTULAS (1)

Fistulae can be divided into

congenital (present frombirth) and acquired types.

The former is rare and is

often associated with other

congenital abnormalities

such an anus that is not

completely patent.

The underlying causes of

acquired GI fistulas are

diverse and can include

virtually any processresulting in bowel

perforation from within or

bowel penetration from an

extraintestinal process .

Fistulae can be divided into

congenital (present frombirth) and acquired types.

The former is rare and is

often associated with other

congenital abnormalities

such an anus that is not

completely patent.

The underlying causes of

acquired GI fistulas are

diverse and can include

virtually any processresulting in bowel

perforation from within or

bowel penetration from an

extraintestinal process .

10:43 4



A- Intestinal Fistulas

*Intestinal fistulas may involve any or all combinations of thesmall bowel, colon, and stomach.

*The clinical manifestation of this subset may be subtle, since

only the alimentary tract is involved. Diarrhea, with or without

abdominal pain, is the most common symptom overall.

*There are several factors that influence which segments of

bowel are involved in the fistulous communication:

1-Proximity to the pathologic process.

2-a preexisting or preferred pathway between certain portionsof the gut, as with a connecting ligament or mesentery.

A- Intestinal Fistulas

*Intestinal fistulas may involve any or all combinations of thesmall bowel, colon, and stomach.

*The clinical manifestation of this subset may be subtle, since

only the alimentary tract is involved. Diarrhea, with or without

abdominal pain, is the most common symptom overall.

*There are several factors that influence which segments of

bowel are involved in the fistulous communication:

1-Proximity to the pathologic process.

2-a preexisting or preferred pathway between certain portionsof the gut, as with a connecting ligament or mesentery.

10:43 6

INTERNAL GI FISTULASINTERNAL GI FISTULAS



A- Intestinal Fistulas(e.g.)A- Intestinal Fistulas(e.g.)

*Enteroenteric and enterocolic fistulas are common

complications of Crohn disease, where fistulas are often

multiple and favor the ileocecal region.

*Enterocolic fistulas in Crohn disease are usually due to

primary small-bowel disease, whereas the opposite is true for

colonic diverticulitis.

*gastrocolic fistula:

The gastrocolic ligament allows for bidirectional spread of

pathologic processes between the greater curve of the

stomach and the transverse colon. Although carcinomas of

the stomach and colon were once thought to be the mostcommon cause of gastrocolic fistula, it now appears that

most cases are due to penetrating benign gastric ulcers,

particularly in the setting of nonsteroidal antiinflammatory

drug use.

*Enteroenteric and enterocolic fistulas are common

complications of Crohn disease, where fistulas are often

multiple and favor the ileocecal region.

*Enterocolic fistulas in Crohn disease are usually due to

primary small-bowel disease, whereas the opposite is true for

colonic diverticulitis.

*gastrocolic fistula:

The gastrocolic ligament allows for bidirectional spread of

pathologic processes between the greater curve of the

stomach and the transverse colon. Although carcinomas of

the stomach and colon were once thought to be the mostcommon cause of gastrocolic fistula, it now appears that

most cases are due to penetrating benign gastric ulcers,

particularly in the setting of nonsteroidal antiinflammatory

drug use.

10:43 7



Enteroenteric and

enterocolic fistulas

Enteroenteric and

enterocolic fistulas

10:43 8

A-Frontal radiograph

from barium-enhancedsmall-bowel study in a

25-year-old man with

Crohn disease shows

multiple fistulous tractsextending from the

terminal ileum(arrowheads), converging

to a small mesenteric

cavity (), and

communicating with thececum and more proximal

ileum (arrows).

A-Frontal radiograph

from barium-enhancedsmall-bowel study in a

25-year-old man with

Crohn disease shows

multiple fistulous tractsextending from the

terminal ileum(arrowheads), converging

to a small mesenteric

cavity (), and

communicating with thececum and more proximal

ileum (arrows).



Colovesical fistula:Colovesical fistula:

Transverse contrast-

enhanced CT scans in a

56-year-old-man with

pneumaturia and prior

diverticulitis show air

(arrowhead) in thebladder and the site of

fistulous communication

(arrow) between

sigmoid colon and

bladder.


enhanced CT scans in a

56-year-old-man with

pneumaturia and prior

diverticulitis show air

(arrowhead) in thebladder and the site of

fistulous communication

(arrow) between

sigmoid colon and

bladder.

10:43 10



B-Biliary tract.

Spontaneous internal biliary fistulasrepresent a complication of

cholelithiasis or choledocholithiasis in

over 90% of cases . Infrequent causesinclude peptic ulcer disease,

malignancy, and prior surgery.

The clinical manifestation ofenterobiliary fistulas is often

nonspecific, and most cases are

diagnosed on the basis of an

unsuspected imaging finding.

Pneumobilia seen on imaging studies

strongly suggests the presence of aninternal biliary fistula in the absence

of prior surgery.

B-Biliary tract.

Spontaneous internal biliary fistulasrepresent a complication of

cholelithiasis or choledocholithiasis in

over 90% of cases . Infrequent causesinclude peptic ulcer disease,

malignancy, and prior surgery.

The clinical manifestation ofenterobiliary fistulas is often

nonspecific, and most cases are

diagnosed on the basis of an

unsuspected imaging finding.

Pneumobilia seen on imaging studies

strongly suggests the presence of aninternal biliary fistula in the absence

of prior surgery.

10:43 11



C-vascular system:

Enteric fistulas involving the

vascular system, whether arterial

or venous, are potentially lethal

and require urgent correction.

he aorta lies in proximity with the

GI tract for much of its thoracic

and abdominal course. Aortoenteric

fistulas, therefore, can potentially

involve the gut anywhere from the

esophagus to the colon .The

majority of cases occur in thepresence of aortic aneurysm

disease

C-vascular system:

Enteric fistulas involving the

vascular system, whether arterial

or venous, are potentially lethal

and require urgent correction.

he aorta lies in proximity with the

GI tract for much of its thoracic

and abdominal course. Aortoenteric

fistulas, therefore, can potentially

involve the gut anywhere from the

esophagus to the colon .The

majority of cases occur in thepresence of aortic aneurysm

disease

10:43 12



D-Respiratory tract:

Acquired esophagorespiratory fistulas

account for the majority of

intrathoracic GI fistulas and consist ofcommunication with either the

tracheobronchial tree or the pleura.

Fistulas that communicate betweenthe respiratory tract and the

intraabdominal GI tract (ie,

gastrobronchial, enterobronchial, and

colobronchial fistulas) are rare but

may result from a penetrating

subphrenic abscess or a postsurgicalcomplication.

Likewise, gastropleural and

colopleural fistulas are also rare andare usually associated with

diaphragmatic herniation or afterpulmonary resection

D-Respiratory tract:

Acquired esophagorespiratory fistulas

account for the majority of

intrathoracic GI fistulas and consist ofcommunication with either the

tracheobronchial tree or the pleura.

Fistulas that communicate betweenthe respiratory tract and the

intraabdominal GI tract (ie,

gastrobronchial, enterobronchial, and

colobronchial fistulas) are rare but

may result from a penetrating

subphrenic abscess or a postsurgicalcomplication.

Likewise, gastropleural and

colopleural fistulas are also rare andare usually associated with

diaphragmatic herniation or afterpulmonary resection

10:43 13



EXTERNAL (CUTANEOUS)FISTULAS

EXTERNAL (CUTANEOUS)FISTULAS

the majority of unintended enterocutaneous fistulas

represent a complication of prior surgery.

Diverticulitis, appendicitis, Crohn disease, and

other causes.

Perianal fistulas are somewhat unusual in that most

appear to be idiopathic in nature or due to Crohndisease.

Factors that predispose to postoperative

enterocutaneous fistula formation include

anastomotic failure (eg, due to inadequate bloodsupply, diseased bowel), adjacent abscess

formation, distal obstruction, and certain

underlying disease processes

the majority of unintended enterocutaneous fistulas

represent a complication of prior surgery.

Diverticulitis, appendicitis, Crohn disease, and

other causes.

Perianal fistulas are somewhat unusual in that most

appear to be idiopathic in nature or due to Crohndisease.

Factors that predispose to postoperative

enterocutaneous fistula formation include

anastomotic failure (eg, due to inadequate bloodsupply, diseased bowel), adjacent abscess

formation, distal obstruction, and certain

underlying disease processes

10:43 14



Enterocutaneous fistulas are further

categorized according to their degree of

fluid production. High-output fistulas drain

more than500 mL/day and generally

originate in the upper GI tract, whereas

low-output fistulas drain less than this

amount and are typically more distal.

Enterocutaneous fistulas are further

categorized according to their degree of

fluid production. High-output fistulas drain

more than500 mL/day and generally

originate in the upper GI tract, whereas

low-output fistulas drain less than this

amount and are typically more distal.

10:43 15



Gastrocutaneous fistulaGastrocutaneous fistula


enhanced CT scan in a 65-

year-old woman with

Crohn disease shows

unsuspected

gastrocutaneous fistula (F).Note soft-tissue thickening

(arrowheads) of theabdominal wall and

stomach. A focal

abdominal bulge was

initially thought at clinicalexamination to be a

ventral hernia becauseoverlying skin was still

intact at that time.


enhanced CT scan in a 65-

year-old woman with

Crohn disease shows

unsuspected

gastrocutaneous fistula (F).Note soft-tissue thickening

(arrowheads) of theabdominal wall and

stomach. A focal

abdominal bulge was

initially thought at clinicalexamination to be a

ventral hernia becauseoverlying skin was still

intact at that time.

10:43 16



Diagnostic StudiesDiagnostic Studies

10:43 17

Cross-sectional imaging, and conventional contrast-

enhanced studies provide complementary

information that allows comprehensive evaluationof most acquired GI fistulas.

Despite this wide variability, some broad comments

can be made with regard to the imaging approach.

A- Contrast-enhanced fluoroscopic examinationsoften remain the initial study of choice and are

generally superior to endoscopy in demonstrating

the presence and extent of a GI fistula.

Fistulography is adequate for diagnosis of mostexternal (cutaneous) fistulas and is also useful for

follow-up in these cases.

Cross-sectional imaging, and conventional contrast-

enhanced studies provide complementary

information that allows comprehensive evaluationof most acquired GI fistulas.

Despite this wide variability, some broad comments

can be made with regard to the imaging approach.

A- Contrast-enhanced fluoroscopic examinationsoften remain the initial study of choice and are

generally superior to endoscopy in demonstrating

the presence and extent of a GI fistula.

Fistulography is adequate for diagnosis of mostexternal (cutaneous) fistulas and is also useful for

follow-up in these cases.



Diagnostic Studies(3)Diagnostic Studies(3) Cross-sectional imaging, particularly computed

tomography (CT), has further strengthened the

radiologist·s for evaluating GI fistulas.

CT effectively complements conventional

radiography with its ability to demonstrate

extraluminal disease, including associatedabscesses, tumor, or other coexisting processes.

Cross-sectional imaging, particularly computed

tomography (CT), has further strengthened the

radiologist·s for evaluating GI fistulas.

CT effectively complements conventional

radiography with its ability to demonstrate

extraluminal disease, including associatedabscesses, tumor, or other coexisting processes.

10:43 19



reatmentreatment

Medical management of patients with GI fistula

should include maintaining fluid and electrolytebalance, providing bowel rest and nutrition support,

initiating medication treatment, ensuring skin

protection.

Affected patients have an inadequate absorption of

nutrients, and are at risk for dehydration andelectrolyte imbalances. The electrolytes sodium,

potassium, magnesium, and phosphate must be

replaced either through total parenteral nutrition

(TPN

) or intravenous therapy. Initiation and maintenance of nutrition are essential

for treating patients with GI fistulas. Bowel rest by

keeping the patient NPO is recommended for at

least 4 to 8 weeks .

Medical management of patients with GI fistula

should include maintaining fluid and electrolytebalance, providing bowel rest and nutrition support,

initiating medication treatment, ensuring skin

protection.

Affected patients have an inadequate absorption of

nutrients, and are at risk for dehydration andelectrolyte imbalances. The electrolytes sodium,

potassium, magnesium, and phosphate must be

replaced either through total parenteral nutrition

(TPN

) or intravenous therapy. Initiation and maintenance of nutrition are essential

for treating patients with GI fistulas. Bowel rest by

keeping the patient NPO is recommended for at

least 4 to 8 weeks .10:43 20



Reference :

radiology.rsna.org.

findarticles.com. Minei, J., & Champine, J. (2002). Abdominal

abscesses and gastrointestinal fistulas. In M.

Feldman, L. Friedman, & M. Sleisenger (Eds.),

Gastrointestinal and liver disease:Pathophysiology/diagnosis/management (7th ed.)

(pp.431-437).

Reference :

radiology.rsna.org.

findarticles.com. Minei, J., & Champine, J. (2002). Abdominal

abscesses and gastrointestinal fistulas. In M.

Feldman, L. Friedman, & M. Sleisenger (Eds.),

Gastrointestinal and liver disease:Pathophysiology/diagnosis/management (7th ed.)

(pp.431-437).

10:43 22



Thank youThank you

10:43 23

Gastrointestinal Fistulas - Mousa Mashagbah

Documents

Transcript of Gastrointestinal Fistulas - Mousa Mashagbah