SPECIFIC TYPES OF FISTULAS

306 Section II / General Surgery

What are the causes?

Anastomotic leak, trauma/injury to the

bowel/colon, Crohn’s disease, abscess,

diverticulitis, inflammation/infection,

inadvertent suture through bowel

What is the workup?

1.

CT scan to rule out abscess/

inflammatory process

2.

Fistulagram

What are the possible

High-output fistulas, malnutrition, skin

complications?

breakdown

What is the treatment?

NPO; TPN; drain abscesses, rule out and

correct underlying causes; may feed distally

(or if fistula is distal, feed elemental diet

proximally); half will close spontaneously,

but the other half require operation and

resection of the involved bowel segment

Which enterocutaneous fistula

Long fistula (may be counterintuitive—

closes faster: short or long?

but true)

COLONIC FISTULAS

What are they?

Include colovesical, colocutaneous,

colovaginal, and coloenteric fistulas

What are the most common

Diverticulitis (most common cause),

causes?

cancer, IBD, foreign body, and irradiation

What is the most common

Colovesical fistula, which often

type?

presents with recurrent urinary tract

infections; other signs include

pneumaturia, dysuria, and fecaluria

How is the diagnosis made?

Via BE and cystoscopy

What is the treatment?

Surgery: segmental colon resection and

primary anastomosis; repair/resection of

the involved organ

What is a cholecystenteric

Connection between gallbladder and

fistula?

duodenum or other loop of small bowel

due to large gallstone erosion, often

resulting in SBO as the gallstone lodges

in the ileocecal valve (gallstone ileus)

Chapter 47 / Fistulas 307

What are the common causes

Penetrating ulcers, gastric or colonic

of a gastrocolic fistula?

cancer, and Crohn’s disease

What are the possible

Malnutrition and severe enteritis due to

complications of gastrocolic

reflux of colonic contents into the stomach

fistulas?

and small bowel with subsequent bacterial

overgrowth

PANCREATIC ENTERIC FISTULA

What is it?

Decompression of a pseudocyst or abscess

into an adjacent organ (a rare complication);

usually done surgically or endoscopically to

treat a pancreatic pseudocyst

EXTERNAL PANCREATIC FISTULA

What is it?

Pancreaticocutaneous fistula; drainage of

pancreatic exocrine secretions through to

abdominal skin (usually through drain

tract/wound)

What is the treatment?

NPO, TPN, skin protection, octreotide

What is a “refractory”

Pancreaticocutaneous fistula that does

pancreatic fistula?

not resolve with conservative medical

management (the minority of cases)

What is the diagnostic test

ERCP to define site of fistula tract

for “refractory” pancreatic

(i.e., tail versus head of pancreas)

fistulas?

How is refractory tail of a

Resection of the tail of the pancreas and

pancreas fistula treated?

the fistula

How is refractory head of a

Pancreaticojejunostomy

pancreas fistula treated?

BLADDER FISTULAS

What are the specific types?

Vesicoenteric (50% due to sigmoid

diverticulitis); signs include

pneumaturia, fecaluria

Vesicovaginal (most are secondary to