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2
Anatomical classification:
(1)
Internal: Two organ of same or different system
▪ Enteroenteral, enterovesical,enterocolic,
External: Gut to body surface.
▪ Gastrocutaneous,duodenocutaneous,
enterocutaneous.
3
(2)
Simple or direct.
Complicated-
1.Having multiple tracts
2.Connection with more
than one viscus
3.drainage into an
associated abscess
cavity.
High output- output more than 500 ml/ day
5
1. Spontaneous(15-25%)-
• Radiation
• Duodenal ulcer
perforation
• Inflammatory bowel
disease
• Malignancies
• Diverticular disease
• Intestinal tuberculosis
• Appendicitis
• Actinomycosis.
• Ischaemic bowel disease
6
• Operations for
perforations .
• Acute intestinal
obstruction
• Intestinal
malignancies
• Adhesiolysis
4. Traumatic
Blunt and penetrating trauma of abdomen, chest
and perineum
8
Disease bowel extending to surrounding structures
bbthapa 9
Small intestinal fistula are most common
type of gastrointestinal fistulas encountered.
bbthapa 10
Malnutriton Mobilisation
Infection Handling
Hypotension Tension
Anemia Ischemia
Hypothermia hemostasis
Poor oxygen delivery
bbthapa 11
Fluid and electrolyte imbalance.
Malnutrition
Sepsis
bbthapa 12
Recognized 5th-10th days Abdominal tenderness
post operatively.
Drainage of enteric
Fever material through the
abdominal wound or
Leucocytosis through or existing
drains.
Prolonged ileus
Varies with anatomical location
14
THE GOAL are
Re-establishment of bowel continuity
Ability to achieve oral nutrition
Closure of the fistula
15
PHASE TIME COURSE
RECOGNITON / 24 TO 48 HRS
STABILISATION
INVESTIGATON 7- 10 DAYS
DECISION 10 DAYS TO 6 WEEKS
DEFINITIVE WHEN CLOSURE UNLIKELY OR
MANAGEMENT 4-6 WKS
HEALING 5 – 10 DAYS AFTER CLOSURE
UNTILL FULL ORAL NUTRITON
16
Resuscitation
Control of sepsis
Electrolyte repletion
Control of fistula drainage
Local skin care n protection
Provision of nutrition
bbthapa 17
Restoration of normal circulating blood volume
20
T
Problems in skin around the fistula:
Wetness
Burning pain
Discomfort from skin edema
22
Solid wafers (pectin based)
Paste
May be:
▪ Enteral
▪ Parenteral
bbthapa
26
Objectives of investigation plan: To define-
Abscess cavity
MRI
28
By using water soluble gastrograffin is the
investigation of choice
length and diameter of the tract
site of bowel wall defect
health of the adjacent bowel,
and the presence of strictures
abscess cavities
distal obstruction
anastomotic dehiscence.
Gastro cutaneous fistula
bbthapa 31
No signs of imminent closure after 4- 6 weeks then
patient should be prepared for surgery
32
Optimal nutrition parameters
Free of sepsis
Well healed abdominal wall without inflammation
Prophylactic antibiotics
Tapering of tube feeding
Prevent contamination of abdominal wall tissues
Treat the cause
33
a. Foreign Body
b. Radiation
c. Inflammation/ infection
d. Epithelialisation [F-R-I-E-N-D-S]
e. Neoplasm
f. Distal intestinal obstruction
g. Steroids.