Pathology

1. Enterocutaneous fistula: abnormal connection between skin and the gastrointestinal tract
2. Aetiology
   • Inflammation: IBD, Diverticular disease, TB
   • Malignancy: following rupture of an abscess
   • Radiotherapy: pelvic irradiation
   • Trauma: penetrating wounds to the abdomen, especially involving the perforation of bowel
   • Post-surgery: anastamotic leak
3. Classification
   • Anatomical
   • High / low 

Approach

• Expose patient for abdominal examination
• Inspect abdominal wall - do not beign with the hands

1. Inspect
   • Appearance of fistula - site, size, discharge, surrounding skin
   • Rest of abdominal wall - recent scar, anastamotic leak, previous surgery (esp for malignancy or IBD), presence of stoma
   • General condition of the patient
   • Drips / parenteral nutrition
   • Catheters / central venous pressure lines
2. Palpate
3. Percuss
4. Auscultate

Completion

1. Look for underlying cause

Investigations

1. Blood tests
   • FBC - anaemia
   • Electrolytes
   • Inflammatory markers
   • LFTS- albumin and malnutrition
2. Radiological investigations
   • Fistulogram: injection of contrast material into fistula opening in order to see where the fistula connects to the bowel
   • USS / CT: determine extent of cavity and detect underlying pathologies
   • Barium follow through

Principles of treatment

1. Control sepsis
2. Nutrition
3. Define anatomy
4. Procedure