Fistula Management p266 Flashcards
Terminology (names of fistulas)
Point of origin to point of termination/drainage: colo = colon entero = small bowel vesico = bladder vaginal = vagina cutaneous = skin recto = rectum
Classified by volume of output High output >500 cc+/24h Low-moderate output = fistual <500cc/24h simple vs complex Simple (directly to skin, no abscess or organs) Complex Type 1: fistula w/ abscess or other organ Type 2: Fistula opening to base of wound
Common types of fluid electrolyte imbalance
small bowel drainage: Na, K, HCO3
GOAL: prevent hypovolemia & metabolic acidosis w/ hypoK, hypoNa
Usual medical management and rationale
Dx:
Origin & termination of fistula
obstacles to closure (distal obstruction, abscess, pseudostoma formation)
r/o Sepsis & fluid electrolyte imbalance
Workup: GI series, fistulogram w/ H20 soluble dye (gastrograffin) or CT scan
Assessment factors: factors impeding fistula closure
mucosal eversion pseudostoma large bowel wall defects high volume output long fistula tract previous radiation sepsis malnutrition intraabdominal adhesions (scar tissue) purulent drainage from fistula tract
Importance nutritional support and selection appropriate option based on pt Scenario
limit oral/enteral intake (20% calories via oral/enteral route to prevent mucosal atrophy)
TPN (calories, proteins, vitamins, minerals, Vit C & Zn)
elemental diet if fistula distal (rectosignmoid)
feed past jejunum
Role of VAC and somatostatin in fistula closure
VAC (NWPT) collapse of fistula track
white sponge in bed, silicone adhesive contact layer between wound bed & black sponge)
150mmHg suction continuous up to 200mgHg (25mmHg increments)
2-3 weeks
stop if unable to collapse fistula track after 2 drsg changes (expensive therapy)
Somatostatin (sandostatin) reduces intestinal secretions, promotes fistula closure for high vol fistulas
Options for managing fistulas when standard pouching doesn’t work
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