Introduction
A fistula is an abnormal connection between the organs or body structures within the human body. An intestinal fistula is a rare yet serious condition in which the fistula connects the intestine (both the small and large intestines) with other adjacent organs or surfaces. The disease occurrence rate and the death rate are quite high among the patients who develop intestinal fistula, particularly gastrointestinal fistula.
Most fistula, up to 85%, occur as a result or complication of abdominal surgery. Further complications of fistula development results in an increased risk of complications such as abscess, infection, sepsis, malnutrition, blood loss or anemia, and eventually death. It also increases the hospital stay and financial burden on the patient, and the patient also faces psychological challenges.
What Is a Fistula?
A fistula is an abnormal connection between two structures within the human body. It generally connects two hollow surfaces.
What Is an Intestinal Fistula?
It is a type of fistula that connects the intestine (both the small and large intestines) with other adjacent organs or surfaces.
Fistulae are named according to the body structure or organ involved. The name of the structure or organ from where the fistula starts comes first, after which the name of the structure or organ to where the fistula ends comes second. For example, entero-vesical fistula, in which the fistula starts from the intestine and ends in the bladder.
What Are the Common Examples of Intestinal Fistula?
Examples of intestinal fistula include:
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Enterocutaneous Fistula - A fistula formed between the intestine or stomach and the skin.
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Entero-Enteric Fistula - A fistula formed within the intestines.
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Entero-Vesical Fistula - A fistula formed between the intestine and bladder.
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Entero-Colic Fistula - A fistula formed between the intestine and colon.
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Entero-Atmospheric Fistula - A fistula formed between the intestine and atmosphere.
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Recto-Vaginal Fistula - A fistula formed between the rectum and vagina.
What Causes Intestinal Fistula?
The common causes of Intestinal Fistula are:
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Surgical Complication: An intestinal fistula develops as a result of surgical complications and is the most common cause.
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Complex Diverticular Disease: It is the most common cause of fistula that connects internal organs such as the bladder. It occurs because of wearing off the walls of the diverticula wall because of increased pressure on the walls. The inflammation and/or abscess formation may extend to the bladder and create a fistula.
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Chronic Inflammatory Bowel Disease: The Crohn's fistula complication commonly causes fistula such as entero-colic fistula.
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Cancer: Cancer or malignancy of the intestine or other organs causes a fistula and is called a malignant fistula.
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Radiation: Exposure to radiation causes chronic or long-standing inflammation and a poor healing process. This causes intestinal fistula.
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Trauma: Injuries and trauma cause an abnormal connection with the intestine - fistula.
What Are the Symptoms of Intestinal Fistula?
The commonly occurring symptoms are:
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Pain in the abdomen.
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Diarrhea.
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Weakness.
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Loss of appetite.
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Weight loss.
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Gastrointestinal bleeding.
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Vaignal pain and discharge if the fistula involves the vagina and rectum.
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Recurrent infections such as urinary tract infections.
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Skin irritation and pain in enterocutaneous fistula.
How to Detect Intestinal Fistula?
The evaluation and detection of Intestinal Fistula depend on its severity.
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Clinical Examination: It includes reviewing the medical history of the patient and careful physical examination of the affected area, which is the abdomen.
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Imaging Tests: Ultrasound and computed tomography are performed to confirm the presence of an intestinal fistula. The contracting images of the gastro-intestinal tract show the presence and extent of the fistula. The starting structure shows the contrasting image, but it is difficult to detect the endpoint or organ. Sometimes, a magnetic resonance imaging test is done if the fistula is complicated to detect because this test provides better soft tissue characteristics.
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Endoscopy: It provides detailed information about the fistula and the underlying disease, such as cancer.
How Is Intestinal Fistula Treated?
The intestinal fistula treatment includes treating the fistula and the underlying cause of the disease. Generally, the fistula heals on its own and does not require any surgical treatment.
Non-surgical Treatment
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Symptoms related to infections such as urinary tract infection, dehydration, skin infection, inflammation, etc., must be treated.
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Codeine and Loperamide can help reduce gut secretions.
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Enteral feeding - providing nutrition to the patient through a tube so that the food directly goes into the stomach or intestine.
Surgical Treatment
If the fistula does not heal on its own in a few weeks or months, then a complex surgery is required to close the fistula. The main aim of the surgical approach is to remove the fistula through excision. There are various surgical techniques available:
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Incision and Drainage: A cut or incision is made into the fistula, and the fluid is drained out. It will prevent the accumulation of fluids and infection.
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Excision: Limited surgical excision is preferred. More radical excision is performed in malignancies. Excision of the intestine is also important. Along with excision, debridement of the infected tissue is done, and the fistula is closed for healing.
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Fistulotomy: Along with the excision of the intestine, the fistula is cut and removed completely.
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Endoscopic Fistula Closure: It includes the closure of the fistula through an endoscope - a tube-like structure with a camera that helps the doctor to see the internal structures, locate the fistula and close it.
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Fibrin Glue: It includes injecting glue into the fistula to close the fistula opening and heal.
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Medical Plug or Intestinal Plug: It is a bioprosthetic plug; cone-shaped; made of animal tissue; used to seal or close the fistula opening internally.
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Seton Technique: A seton is a silk-like surgical thread that is put into the fistula for a few weeks. It helps the fistula to drain and heal.
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Advancement Flap Procedure: If the fistula passes the deep muscles, then the fistula is cut or scraped, and the entry point or hole is covered with a tissue or skin flap.
What Are the Complications of Intestinal Fistula Surgery?
The possible complications are:
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Infection at the surgery site.
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Recurrence of the fistula.
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Bowel incontinence - It is the inability to control bowel movements and the stool leaks from the rectum.
What Is the Differential Diagnosis of Intestinal Fistula?
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Abdominal abscess.
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Appendicitis - A condition in which the appendix becomes inflamed, gets filled with pus, and becomes painful. Generally, in this condition, the appendix is removed.
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Cystitis - Cystitis is a bacterial inflammation of the urinary bladder that is more commonly seen in women.
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Blunt abdominal trauma - A trauma to the abdomen that occurs due to an accident from a motor vehicle, fall from height, assault, etc.
What Is the Intestinal Fistula Surgery Recovery Time?
Most fistula surgery heals within six weeks, depending on the size of the fistula. Small fistula closures heal within 60 days.
Conclusion
Intestinal fistula is a challenging and complicated condition that requires complex surgery. There is no effective treatment option available; therefore, treatment planning should be done based on the patient’s condition, severity, risk factors, age, possible complications, etc. The conservative approach includes antibiotic therapy and management of related symptoms. The surgical approach includes fistulotomy, surgical excision, endoscopic fistula closure, etc.
