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Enterocutaneous Fistula

I. Background

The major cause of enterocutaneous (EC) or enteroatmospheric (EA) fistulas is surgical intervention, accounting for 80% of cases. Non-surgical etiologies include inflammatory bowel disease, radiation, malignancy, and ischemia. While acute management may follow this PMG, the long-term approach to non-surgical fistulas differs and is not addressed here.

These fistulas have high morbidity and mortality, often requiring months to years of wound care and supplemental nutrition, including parenteral nutrition. Reported mortality rates range from 6% to 33%.

II. Terminology

  • Fistula: Abnormal connection between two epithelialized surfaces
  • Enterocutaneous fistula: Abnormal connection between GI tract and skin
  • Gastrocutaneous fistula: Abnormal connection between stomach and skin (often post-gastrostomy)
  • Enteroatmospheric fistula: Bowel-to-skin connection without an epithelialized tract

III. Classification

  • Low output: < 200 cc/day
  • Moderate output: 200–500 cc/day
  • High output: > 500 cc/day

IV. Management

A. Resuscitate and Replace Electrolytes

  • Patients may have large fluid losses and electrolyte disturbances
  • Admit to stepdown or ICU based on clinical status
  • Common abnormalities: hyponatremia, hypokalemia, hypomagnesemia

B. Wound and Skin Protection

  • Control effluent early to prevent skin breakdown and promote successful pouching
  • Initiate pouching with early WOCN (wound ostomy continence nurse) consultation

C. Control Sepsis

  • Percutaneous drainage may help divert effluent and improve wound care
  • Antibiotics:
    • Not required unless systemic sepsis or cellulitis is present
    • If systemic sepsis:
      • First-line: Piperacillin/Tazobactam
      • Severe PCN allergy: Cefepime + Metronidazole

D. Quantify Output

  • Document daily volume output to assist with nutrition and fluid planning

E. Nutrition Optimization

  • Low to moderate output: prioritize enteral nutrition
  • High output: consider NPO and initiate parenteral nutrition
  • Involve Gastroenterology and Nutrition early

F. Operative Management

  • Immediate surgery is rarely helpful in newly presented fistulas
  • If associated with necrotizing soft tissue infection (NSTI), manage per NSTI guidelines
  • If the fistula does not resolve with non-operative management and discharge criteria are met, plan elective fistula takedown

G. Nonsurgical Options

  • Consider endoscopic or percutaneous management if anatomically feasible

V. Flowchart

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VI. References

  1. Cowan KB, Cassaro S. Enterocutaneous Fistula. StatPearls, 2023.
  2. Gribovskaja-Rupp I, Melton GB. Enterocutaneous Fistula: Proven Strategies and Updates. Clin Colon Rectal Surg. 2016;29(2):130–137.
  3. Edmunds LH Jr, et al. External Fistulas of the GI Tract. Ann Surg. 1960;152(3):445–471.
  4. Ballard DH, et al. Percutaneous Management of EC Fistulae. Dig Dis Interv. 2018;2(2):131–140.
  5. Metcalf C. Management of Enterocutaneous Fistula. Br J Nurs. 2019;28(5):S24–S31.
  6. Gross DJ, et al. Challenge of Uncontrolled Enteroatmospheric Fistulas. Trauma Surg Acute Care Open. 2019;4(1):e000381.
  7. Schecter WP, et al. Principles of Enteric Fistula Management. J Am Coll Surg. 2009;209(4):484–491.

VII. Authors

  • Mina F. Nordness, MD, MPH
  • H. Andrew Hopper, MD
  • Michael C. Smith, MD