gastrointestinal fistulas - mousa mashagbah
TRANSCRIPT
8/7/2019 Gastrointestinal Fistulas - Mousa Mashagbah
http://slidepdf.com/reader/full/gastrointestinal-fistulas-mousa-mashagbah 1/23
8/7/2019 Gastrointestinal Fistulas - Mousa Mashagbah
http://slidepdf.com/reader/full/gastrointestinal-fistulas-mousa-mashagbah 2/23
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.
8/7/2019 Gastrointestinal Fistulas - Mousa Mashagbah
http://slidepdf.com/reader/full/gastrointestinal-fistulas-mousa-mashagbah 3/23
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
8/7/2019 Gastrointestinal Fistulas - Mousa Mashagbah
http://slidepdf.com/reader/full/gastrointestinal-fistulas-mousa-mashagbah 4/23
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
8/7/2019 Gastrointestinal Fistulas - Mousa Mashagbah
http://slidepdf.com/reader/full/gastrointestinal-fistulas-mousa-mashagbah 5/23
8/7/2019 Gastrointestinal Fistulas - Mousa Mashagbah
http://slidepdf.com/reader/full/gastrointestinal-fistulas-mousa-mashagbah 6/23
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
8/7/2019 Gastrointestinal Fistulas - Mousa Mashagbah
http://slidepdf.com/reader/full/gastrointestinal-fistulas-mousa-mashagbah 7/23
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
8/7/2019 Gastrointestinal Fistulas - Mousa Mashagbah
http://slidepdf.com/reader/full/gastrointestinal-fistulas-mousa-mashagbah 8/23
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).
8/7/2019 Gastrointestinal Fistulas - Mousa Mashagbah
http://slidepdf.com/reader/full/gastrointestinal-fistulas-mousa-mashagbah 9/23
8/7/2019 Gastrointestinal Fistulas - Mousa Mashagbah
http://slidepdf.com/reader/full/gastrointestinal-fistulas-mousa-mashagbah 10/23
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.
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.
10:43 10
8/7/2019 Gastrointestinal Fistulas - Mousa Mashagbah
http://slidepdf.com/reader/full/gastrointestinal-fistulas-mousa-mashagbah 11/23
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
8/7/2019 Gastrointestinal Fistulas - Mousa Mashagbah
http://slidepdf.com/reader/full/gastrointestinal-fistulas-mousa-mashagbah 12/23
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
8/7/2019 Gastrointestinal Fistulas - Mousa Mashagbah
http://slidepdf.com/reader/full/gastrointestinal-fistulas-mousa-mashagbah 13/23
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
8/7/2019 Gastrointestinal Fistulas - Mousa Mashagbah
http://slidepdf.com/reader/full/gastrointestinal-fistulas-mousa-mashagbah 14/23
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
8/7/2019 Gastrointestinal Fistulas - Mousa Mashagbah
http://slidepdf.com/reader/full/gastrointestinal-fistulas-mousa-mashagbah 15/23
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
8/7/2019 Gastrointestinal Fistulas - Mousa Mashagbah
http://slidepdf.com/reader/full/gastrointestinal-fistulas-mousa-mashagbah 16/23
Gastrocutaneous fistulaGastrocutaneous fistula
Transverse contrast-
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.
Transverse contrast-
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
8/7/2019 Gastrointestinal Fistulas - Mousa Mashagbah
http://slidepdf.com/reader/full/gastrointestinal-fistulas-mousa-mashagbah 17/23
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.
8/7/2019 Gastrointestinal Fistulas - Mousa Mashagbah
http://slidepdf.com/reader/full/gastrointestinal-fistulas-mousa-mashagbah 18/23
8/7/2019 Gastrointestinal Fistulas - Mousa Mashagbah
http://slidepdf.com/reader/full/gastrointestinal-fistulas-mousa-mashagbah 19/23
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
8/7/2019 Gastrointestinal Fistulas - Mousa Mashagbah
http://slidepdf.com/reader/full/gastrointestinal-fistulas-mousa-mashagbah 20/23
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
8/7/2019 Gastrointestinal Fistulas - Mousa Mashagbah
http://slidepdf.com/reader/full/gastrointestinal-fistulas-mousa-mashagbah 21/23
8/7/2019 Gastrointestinal Fistulas - Mousa Mashagbah
http://slidepdf.com/reader/full/gastrointestinal-fistulas-mousa-mashagbah 22/23
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
8/7/2019 Gastrointestinal Fistulas - Mousa Mashagbah
http://slidepdf.com/reader/full/gastrointestinal-fistulas-mousa-mashagbah 23/23
Thank youThank you
10:43 23