Abdominopelvic Fistulas

Overview

Abdominopelvic fistulas are abnormal epithelial-lined connections between organs of the abdomen and pelvis, or between an organ and the skin. They may be:

• Enterocutaneous fistula (bowel → skin)

• Rectovaginal fistula (rectum → vagina)

• Vesicovaginal fistula (bladder → vagina)

• Enterovesical fistula (bowel → bladder)

• Colocutaneous fistula (colon → skin)

Causes include surgical complications, Crohn’s disease, radiation injury, cancer, trauma, and infections. Symptoms vary depending on the tract but may include fecal or urinary leakage, chronic infection, abscess formation, malnutrition, and skin irritation.

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Treatment Options

1. Conservative/Medical Management

(May be appropriate for low-output, non-complex fistulas without sepsis or obstruction)

• Fluid & Electrolyte Management: IV fluids, electrolyte correction.

• Nutritional Support:

  • Enteral feeding if tolerated.

  • Total parenteral nutrition (TPN) in high-output or non-healing cases.

• Infection Control:

  • Broad-spectrum antibiotics (e.g., piperacillin–tazobactam 4.5 g IV q6–8h) if sepsis present.

• Pharmacological Adjuncts:

  • Octreotide: 50–100 mcg subcutaneously every 8 hours to reduce fistula output.

  • Proton pump inhibitors (e.g., omeprazole 20–40 mg PO/IV daily) to reduce gastric secretions in high-output enteric fistulas.

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2. Local & Wound Care

• Skin protection: barrier creams (zinc oxide), pouches for external drainage.

• Negative pressure wound therapy (NPWT): promotes healing and controls effluent.

• Drainage of abscesses if present (surgical or percutaneous).

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3. Definitive Surgical Management

• Indicated if:

  • Fistula persists > 3–6 months despite conservative measures.

  • High-output fistula with malnutrition/sepsis.

  • Underlying disease (tumor, Crohn’s stricture, radiation damage) requires correction.

• Surgical options:

  • Excision of fistula tract.

  • Resection of diseased bowel/organ with re-anastomosis.

  • Flap repair for rectovaginal or vesicovaginal fistulas.

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Supportive Care

• Psychological support due to chronic drainage and body image issues.

• Physiotherapy for pelvic floor dysfunction in rectovaginal/vesicovaginal fistulas.

• Multidisciplinary management involving surgeons, gastroenterologists, nutritionists, and wound care specialists.

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Key Notes

• Low-output fistulas (<200 mL/day) may close spontaneously with conservative management.

• High-output fistulas (>500 mL/day) usually require surgical repair.

• Control of sepsis, nutrition, and skin care are the pillars of management.

• Crohn’s-related fistulas often need biologic therapy (e.g., infliximab 5 mg/kg IV at weeks 0, 2, and 6) before surgery.