A fistula is an abnormal epithelialized tract between two or more structures or spaces.It may involve a communication tract from one body cavity or hollow organ to another hollow organ or to the skin.It is estimated that 90% of ECF arise from surgical procedures. It occurs due to unintentional enterotomy and anastomotic breakdown as a result of a foreign body close to the suture line, tension on the suture line, complicated suturing techniques, distal obstruction, hematoma, abscess formation at the anastomotic site, or tumor.Emergent/urgent surgeries involving unprepped bowel, underresuscitation, malnourishment or previously radiated tissues are other causes for fistula development.Spontaneous fistulas can develop due to crohn's disease, malignancy, infectious processes as in tuberculosis, diverticulitis, vascular insufficiency, radiation exposure and mesentric ischemia.
Fistulas can be classified according to complexity, anatomic location or physiology. Excess fluid exudating from a wound or cutaneously is the usual first indication of an external fistula.Skin excoriation rapidly occurs secondry to the high concentration of digestive enzymes in the chyme. Internal fistulas are fissuring tracts inside the body, which erode directly into adjacent viscus. These are asymptomatic unless the distal portion of the fistula enters a structure such as the bladder , rectum or vagina. Symptoms such as recurrent diarrhea with mucus, blood, cystitis, pneumaturia, flatus or stool from the vagina, perianal/perineal skin excoriation, pressure and discomfort, should all point towards an investigation for the presence of a fistula.
Closure of the fistula either spontaneously or surgically is the ultimate goal. The five main objectives towards caring for fistula are - 1.)Fluid and electrolyte replacement. 2.) Adequate nutrition.The route of nutritional support will take the form of oral, enteral or parenteral nutrition dependent upon patient tolerance, ability to ingest sufficient quantities, the fistula tract location and bowel mucosa's absorptive capacity. 3.)Perifistular skin protection and containment of fistula effluent , which in itself is a complex challenge. Advanced assessment skills, knowledge of appropriate product selection, competence in product application and teaching of the same is very important . 4.) Infection control with use of antibiotics .5.) measures to facilitate closure of the fistula.
Medical and nursing care demand a complementary, interdisciplinary approach if successful closure of an enterocutaneous fistula is to be achieved. The patient and the family are challenged by physical and psychological stressors, which is often the result of weeks of hospitalization.As health careproviders, we should remember to treat the patient as a whole person and not 'just as a hole'. The fistula should not become the only focus of care, but rather an element of the overall treatment plan.