clinical

Considerations for the management

of enterocutaneous fistula
Abstract
Enterocutaneous fistula is an abnormal connection between the gastrointestinal tract and skin. Management
includes early recognition and treatment of sepsis, reducing fluid and electrolyte homeostasis, nutrition
support, wound management and a carefully timed surgical procedure. A multidisciplinary approach is
required for successful management of these patients with one of the most challenging and resource-
demanding aspects being local control of the effluent, requiring the skill and support of the specialist stoma
care nurse. The inability to contain the fistula can be a source of morbidity for the patient, as they will
experience pain and severe discomfort from the skin when leakages occur. Enterocutaneous fistula can result
in intestinal failure, which is often fatal if not managed correctly.

E
Christine Metcalf, Stoma
Care Clinical Nurse Specialist,
St Mark’s Hospital, London
North West NHS Trust,
cmetcalf@nhs.net
Key words
„„Enterocutaneous fistula 
„„Intestinal failure
„„Stoma care 
„„Nutrition
nterocutaneous fistula (ECF) occurs when
there is an abnormal communication
between the gastrointestinal (GI) tract and
the skin. It may be caused by disease processes
such as Crohn’s disease, or iatrogenic (Dastur
et al, 2015). Between 75% and 85% of ECFs
are iatrogenic, resulting from trauma related
to surgery. When fistulae occur in the small
bowel about half are from an anastomotic leak
and half from inadvertent injury to the small
bowel during dissection (Gribovskaja-Rupp and
Melton, 2016).
Initial efforts to manage ECF require input from
the multidisciplinary team as success of further
definitive surgical treatment relies on the patient
being in optimal physical and psychological
condition. The management involves reducing
fluid losses, providing nutrients with fluids and
treating the underlying cause and sepsis. Early
wound management from a nurse specialist in
stoma care is critically important to minimise the
effluent-associated skin damage (Adaba et al,
2017).
Intestinal failure
ECF can result in intestinal failure (IF), which is
often fatal if not managed properly (Adaba et al,
2017). This is when the gut function is reduced
so far it falls below the minimum necessary
for the absorption of macronutrients and/or
water and electrolytes, such that intravenous
supplementation is required to maintain health
and/or growth (Pironi et al, 2015). IF can be
classified into three types according to its
onset, metabolic and expected outcome criteria
(Grainger et al, 2018) (Table 1). Acute IF, which
typically lasts from a few days to months, may
arise from ECF, high-output stoma, small bowel
dysfunction, postoperative ileus or bowel
obstruction, whereas chronic IF can be attributed
to short gut, gut bypass, small bowel motility
disorders or chronic persistence of any acute
intestinal aetiology (Adaba et al, 2017).
If a patient does not have GI function after 5
days following surgery further investigation may
be required, depending on their overall status.
Clinical assessment and metabolic factors such as
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„„Wound care
This article has been subject
to double-blind peer review
Minimising the risk factors prior to the abnormal electrolytes should be reversed and a CT
initial surgery helps to reduce the incidence of scan performed to rule out intra-abdominal sepsis
anastomotic leak and sepsis occurring (Grainger or a leak. Early involvement of the nutritional
et al, 2018). team is beneficial to prevent malnutrition, thus

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reducing the risk of further deterioration of an
already debilitated patient. Parenteral nutrition
is generally indicated if the patient has failed to
tolerate an adequate enteral diet for 5–7 days
(Grainger et al, 2018).
Sepsis control
Early recognition and management of sepsis is
important and should be managed according
to local protocols (trust’s sepsis bundle) with
resuscitation and rapid commencement of the
appropriate antibiotic. Identifying the source of
the sepsis is a priority and any abscesses within
the abdomen should be drained percutaneously.
However, if collections are inaccessible or there
is an anastomotic leak with peritonitis, radiology
imaging-guided drainage may not be possible.
For these patients an early return to surgery may
be required. However, if it is more than 10 days
after the original surgery the surgeon will find
entering the peritoneal cavity challenging due to
fibrotic adhesions therefore making the surgery
technically very difficult. In these circumstances
the minimum amount of surgery should be
undertaken to enable adequate drainage of
infection, resection of any perforation and
then formation of stomas. Once acute sepsis
and urgent conditions requiring interventions
have been excluded and immediate nutrition
addressed to stabilise the patient, further work
up for reconstructive surgery becomes key (Box 1)
(Grainger et al, 2018).
Once the patient has become stable the onset
of infection may be less obvious with no evidence
of pyrexia or rise in white cell count. This is
because a chronic infection may manifest itself
with difficulty in gaining weight, hypalbuminemia,
hyponatremia and even jaundice. Spontaneous
healing of a fistula is less likely in the presence
of active infection and resolution of sepsis is
fundamental for maintaining adequate nutrition
(Grainger et al, 2018).
Once the patient has become stable the onset
of infection may be less obvious with no evidence
of pyrexia or rise in white cell count. This is
because a chronic infection may manifest itself
with difficulty in gaining weight, hypalbuminemia,
hyponatremia and even jaundice. Spontaneous
© 2019 MA Healthcare Ltd
healing of a fistula is less likely in the presence
of active infection and resolution of sepsis is
fundamental for maintaining adequate nutrition
(Grainger et al, 2018).
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036_GASN_2019_17_4_36_42_Enterocutaneous fistula.indd 37
clinical
Table 1. Types of intestinal failure
Type Description
1 • Short term, acute (lasting <28 days)
• Can be related to postoperative ileus or acute intestinal obstruction
• May require short-term parenteral nutrition
• Expected to return to full intestinal autonomy with time
2 • Prolonged condition (>28 days)
• Requires artificial nutrition
• Tends to involve medically unstable patients, i.e. those who have
suffered septic, metabolic and nutritional complications as a result of
major abdominal surgery
• Typical patients include those with complex Crohn’s disease, intestinal
fistula or abdominal sepsis
• Require multidisciplinary approach with metabolic and nutritional
support for recovery pending spontaneous resolution or surgical
treatment
• Expected to return to full intestinal autonomy with time
3 • Chronic intestinal dysfunction requiring long-term parenteral support
• May be irreversible
• Occurs as a consequence of short bowel syndrome, due to loss of
length of small bowel from a massive small bowel resection or due to
loss of absorptive capacity of small bowel
Source: Grainger et al, 2018
Management of
enterostomy output
Enterostomy output can mostly be controlled with
appropriate management involving restriction
of fluids, dietary modification and medications
(Adaba et al, 2017) (Table 2).
Fluids and electrolytes
Management initially involves reducing fluid
losses, which is done by restricting oral fluid intake
and replacing with intravenous rehydration. Oral
fluid intake may be restricted to 1000 ml hypotonic
fluid and 1000 ml hypertonic fluid a day. If dietary
and fluid restrictions fail to reduce output then
patients may be put nil by mouth to assess gastric
secretions. Hypotonic fluids should be avoided as
they cause water and sodium to diffuse into the
Box 1. Work up for
reconstructive surgery
• Sepsis control
• Fluid and electrolyte resuscitation
• Optimisation of nutritional status
• Contaminated wound (ECF) care
• Appropriate surgery
• Active rehabilitation
Source: Grainger et al, 2018
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09/05/2019 14:43
 clinical

individual patient by route and quantity Enteral

Table 2. Treatment for high-output enterostomy
feeding is the route of choice in all patients
1. Check for causes with a functioning GI tract but may be limited
• Take history including medications due to the presence of inflammation, strictures,
• Review operative and pathological reports obstruction, radiation damage, short bowel and
• Examine patient intestinal fistulas. However, enteral feeding not
• Investigations only reduces the complications from parenteral
2. Reduce fluid and electrolyte losses nutrition, it is also important for the psychological
health of these patients (Grainger et al, 2018).
• Reduce fluid and electrolyte losses
Parenteral nutrition tends to be the mainstay
• Rehydrate with intravenous fluid
of nutrition for patients with IF but long-term
• Restrict hypotonic oral fluid intake to 1000 ml/day (1 litre/day)
• Introduce hypertonic fluids as necessary complications include complications related to
• Commence loperamide 2 mg four times daily ± codeine phosphate twice daily intravenous access and liver disease. In reality
as required (loperamide dose can be increased up to 64 mg four times daily patients may need a combination of both enteral
until a satisfactory output of <1500 ml is maintained) and parenteral nutrition depending on the
• Start omeprazole 40 mg daily or twice daily to reduce volume of gastric degree of dysfunction of their GI tract. What is
secretions
important is that they receive adequate nutrition
• Treat underlying causes of losses and stop medications that increased output
(e.g. metoclopramide) to meet their metabolic needs to prepare them
• Screen for malnutrition and refer to dietician as appropriate for reconstructive surgery. This process can take
• Monitor fluid balance, serum electrolytes and weight several months, preferably with nutritional support
• Supplement electrolytes if required at home where patients can eat familiar food,
• Review stoma output in 48–72 hours and if settles increase oral intake mobilise more, feel psychologically normal and
3. Ongoing management reduce the risk of healthcare-acquired infections.
Input from a specialist nutrition support team is
• Continue oral restriction
required to facilitate the transition of patients’
(if output >3000  ml/day, consider complete restriction (nil by mouth) for 24
hours to assess gastrointestinal secretion) care from hospital to home (Grainger et al, 2018).
• Commence St Mark’s electrolyte solution 1000 ml daily, and hypertonic fluids Once it is clear that a fistula is established there
1000 ml daily is no evidence that oral intake will prevent healing.
• Once IV fluids are stopped, check random urine sodium (target is >20  mmol/litre) Eating is psychologically beneficial and frequent
• Continue omeprazole 40 mg daily or twice daily to reduce volume of meals can enhance the number of calories
gastric secretions
absorbed (Grainger et al, 2018). Efforts should
Source: Adaba et al, 2017 be focused on implementing a high-calorie, low-
fibre diet as a low-fibre diet passes slowly through
Table 3. St Mark’s solution the small bowel, thereby increasing nutrient
absorption (Adaba et al, 2017).
Component Amount added to 1 litre water
Sodium chloride 3.5 g Pharmacotherapy
Sodium bicarbonate 2.5 g Medications may be used to reduce gut secretions
Glucose 20.0 g and reduce ECF output. Antidiarrheal medications
Note: To be sipped throughout the day, with or without flavouring such as loperamide and codeine phosphate can
Source: Nightingale, 2003 be given to reduce bowel motility and are often
used in high doses (see Table 2). They should be
administered prior to meals for optimal effect.
intestinal lumen resulting in increased intestinal Antisecretory medications such as proton pump
losses (Adaba et al, 2018). Electrolyte solutions inhibitors, histamine blockers (H2 antagonists)
such as St Mark’s solution can be given to replace and somastostatin analogue (octreotide) may be
electrolyte losses (Table 3) and oral magnesium added in (Adaba et al, 2017).
when required (Nightingale, 2003). It is not uncommon for patients with IF and
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ECF to become dependent on both opioid and

Nutritional support non-opioid analgesics. As analgesia administered
A complete nutritional assessment should be orally may not be absorbed in patients with short
undertaken and the regimen tailored to the gut or obstruction and intravenous access can be

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difficult, skin patches can provide more effective faecal fluid washing over a wound bed will lead
pain relief. Involvement of a pain team is advised to infection and further erosion of the wound.
together with access to non-pharmacological However, in the author’s experience in practice this
techniques such as distraction and a psychologist does not happen and the contaminated wound
or psychiatrist with an understanding of addiction continues to heal. Although the mechanism is
(Grainger et al, 2018) poorly understood it may be that faecal fluid
does not provide as hostile an environment as
Wound management previously thought or alternatively providing
of enterocutaneous fistula the wound with a warm moist environment (as
Perhaps one of the most challenging and occurs in an appliance) is the most important
resource demanding aspects of ECF management factor to promote wound healing.
is local control of the effluent (Gribovskaja-Rupp In addition, the patient and ideally their
and Melton, 2016). As the inability to contain family need to be taught how to self-care ready
the fistula can be a source of morbidity for the
patient, causing pain and severe discomfort from Box 2. Princiaples of fistula wound management
moisture-related skin damage when leakages
• Assess contours of patient’s abdomen, getting them to sit forward in order to
occur, the skill and support of the specialist stoma identify dips, gullies and skin creases (Figure 1)
care nurse is required (Grainger et al, 2018). The • Frame edges of wound bed with overlapping cut portions of large washers
aim with management is therefore is to devise and ensuring a good seal is achieved
agree a plan of care with the patient to contain • Fill skin dips, creases and gullies with wedges of washers with or without
the faecal effluent, prevent skin breakdown and stoma paste (Figure 2)
• Fit a suitable appliance over the top (Figure 3)
provide comfort (Association of Stoma Care
• Prepare all equipment and accessories before removing old appliance
Nurses (ASCN), 2016). Practically, this means
• Take time and care with each step of process
providing a leak-proof appliance that lasts for a
• Use suction if necessary, to keep area free from fluid
minimum of 24 hours. • Use piped air to help dry skin and paste (if trust policy allows)
There are a variety of specially designed • Encourage patient to assist (preparing for discharge)
appliances available to use to manage fistula • Establish a routine changing the appliance before it leaks
although some smaller ones can be contained e.g. if it leaks after 3 days, change to alternate days
effectively within a stoma appliance. All fistula • Avoid changing appliance straight after meals (as ECF likely to be more active)
appliances have drainable ports to attach • Advise patient not to mobilise for 30 minutes after appliance change to allow
adhesive to bond
drainage bags and are often used in conjunction
• Appliance should be changed any time it leaks (do not patch)
with other ostomy products such as skin protector
wipes, paste and washers to help the patient to
obtain a satisfactory seal and minimise leakages.
High-output fistulas are the most challenging to
manage, sometimes taking up to 1.5 hours to
change for a particularly complex one. However,
there are some principles that should be followed
(Box 2) and devising a photographic care plan can
be helpful for staff to ensure that care remains
consistent (ASCN, 2016) (Box 3).
Careful assessment of the contaminated
wound is essential if a satisfactory system is to
be found. The size of the fistula and wound bed
(Figure 4) and the type, amount and consistency
of the output needs assessing to assist with
choosing the correct type and size of appliance
to be used. The surrounding skin needs assessing
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to identify skin creases, dips and folds as these

need packing out using a variety of products in
order to establish a flat platform on which to fix Figure 1. ECF in laparotomy wound with fistulated bowel visible. Assessment of
the appliance. It is often assumed that having skin contours is performed to identify dips, gullies and skin creases

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 clinical

for discharge home and complex discharge

arrangements need to be co-ordinated (Box  4).
District nurses may be required to assist or
manage changes in the community and early
follow up from the local stoma care nurse is
essential as problems with the appliance need to
be anticipated and systems modified as patients
become more mobile at home.

New wound management system

Negative pressure therapy is a technique whereby
a vacuum dressing is used to promote wound
healing. As it is becoming commonplace in
managing acute or chronic wounds, it is not
surprising that it is also becoming an option
for the management of ECF (Gribovskaja-Rupp
and Melton, 2016) as it can effectively contain
Figure 2. Filling skin dips, gullies and creases with wedges of washer and/or stoma paste the effluent, protect the surrounding skin and
to establish a flat platform on which to fix the wound manager appliance (a small piece decrease the frequency of bag changes to one to
of alginate dressing has been used to stop a bleeding point in the wound bed) two times a week.
To apply the dressing, the surrounding skin is
first protected by a skin barrier followed by the
application of a transparent film. A foam filler
is then cut and shaped to fit to the contours
of a wound bed (leaving the visible portion of
fistulated bowel exposed) and sealed with a
transparent film (Figure 5). A drainage tube is
connected to the dressing through an opening
of the transparent film which is connected to
the vacuum pump (Baxter and Ballard, 2001). A
stoma appliance (preferably with a tap to be able
to attach a night drainage system) is then applied
over the visible portion of fistulated bowel using
a washer and paste to ensure an adequate seal is
achieved as it is imperative for this to be air tight
if this therapy is to be successful. If this method
of management is chosen support from the tissue
viability nurse is required.
Figure 3. A suitable wound manager for use with ECF

Psychological support
Box 3. Compiling a photo care plan Patients will require psychological support as
Have a regimen proven to work, i.e. appliance lasts at least 24 hours they will often experience anxiety, feelings of
loss, loss of self-esteem, depression and anger,
Trial for 1 week before developing care plan
particularly if they developed an ECF secondary
Aim for it to be manageable at home to a postoperative complication. Patients may
Create care plan also develop body image issues related to
• Gain consent and file form in medical records stomas, fistulas and an open abdomen, which
• Take step by step photos can inhibit recovery. It is therefore important to
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• Download onto shared drive provide explanations at each stage as they can
• Use publisher template to create feel frustrated and struggle to understand the
• Copy: patient notes (medical and nursing), district nurse, GP, carer, family, in benefit of waiting to be medically optimised prior
with supplies, local stoma care nurse and patient
to surgery (Grainger et al, 2018).

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 clinical

Distal feeding provision of nutrition, control of sepsis and

This is when the distal portion of the bowel is minimising output usually within 4-8 weeks. If
used as a site for feeding with nutritional support healing does not occur within this period, plans
being administered either as chyme, elemental for definitive surgery should be initiated (Adaba
formula or fluid. Before initiating distal feeding et al, 2017). However, in a complex abdomen
the anatomy of the bowel and fistula should the process of forming a new peritoneal cavity
be established through radiology imaging to takes around 6 months with the best indicator
ensure that there are no distal enterotomies or that the abdomen is ready for further surgery
obstructions and that the remaining bowel is being the prolapsed portion of bowel (i.e. the
long enough to absorb nutrients. Involvement portion of fistulated bowel that can be visualised
of nurse specialists in nutrition and stoma care is
required to teach the patient how to care for the
tube, administer the feed and provide a suitable
appliance (Figure 6). Distal feeding is increasingly
being used ahead
of surgical reconstruction to maintain the distal
integrity, optimising bowel function following
restoration of bowel continuity (Adaba et al,
2017).

Radiology
The gut should be reviewed radiologically
before any further surgery is undertaken as the
surgeon needs to be confident that there is no
distal narrowing of the gut before attempting
reconstructive surgery. For patients with Crohn’s
disease an MRI may be required to eliminate anal
sepsis and if a patient has had previous complex
surgery involving the urological system, the
urinary tract needs assessing as it may require Figure 4. Enterocutaneous fistula in laparotomy wound with fistulated bowel
protecting by inserting ureteral stents. A CT visible within the wound bed
angiography is required on patients who have
severe cardiovascular disease and have suffered Box 4. Complex discharge planning
extensive mesenteric ischaemia to establish that
• Needs to start on admission
there is sufficient blood supply to the gut. Ideally
• Manage patients’ expectations honestly
the radiological images should be reviewed by a
• Establish if discharge to local hospital or home
radiologist experienced in GI radiology as these • Develop photo care plan
patients can have complex anatomy (Grainger et • Assess if possible, to teach patients/family
al, 2018). • Referral to district nurse
• Invite for teaching sessions
Surgical management • Request early follow up from local stoma care nurse
Approximately 30% of patients with ECF will • Provide extra supplies as a contingency plan anticipating problems
experience healing of the fistula following • Send summary letter/care plan to the multidisciplinary team involved in care

CPD reflective questions

„„Consider the psychological impact having an enterocutaneous fistula (ECF) and extended hospital admission has on a patient and
their family
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„„Are there any aspects of caring for these patients that you feel you have insufficient skills to manage and if so, how might you
address this?
„„Think about a patient you have cared for with an ECF and how their management could have been improved upon

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Figure 5. Negative pressure dressing on wound bed with fistulated bowel exposed.
A stoma appliance will be attached over this to contain the faecal effluent
Figure 6. Feeding tube inserted into distal limb of stoma
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036_GASN_2019_17_4_36_42_Enterocutaneous fistula.indd 42
within the wound bed of the ECF). If surgery is
undertaken before this time, the patient is put at
risk of further injury and complications (Grainger
et al, 2018).
Reconstruction of the abdominal wall is an
important element of the operation as failure
to close the abdomen properly may lead to
further complications such as re-fistulation,
formation of incisional hernia or a poor cosmetic
result. Mesh in the abdomen may be required
to provide support to structures if there are
multiple abdominal or large defects. However, a
non-absorbable one should not be used as it is
thought to be associated with increased infection
rates (Grainger, 2018)
Conclusion
ECF is one of the most challenging postoperative
complications to manage and requires a
multidisciplinary approach if the outcome of closure
is to be successful. Although patients are often
keen to proceed with surgical closure at the earlier
opportunity, they are better off waiting through at
least 6 months of non-surgical management. GN
Declaration of interest  The author has no conflicts of
interest to declare
Note  This article was first published in the British Journal of
Nursing Stoma Supplement 2019 28(5):S24–S31
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