Faecal Fistula
Faecal Fistula Classification:
Depending upon the Nature of the Disease or a Surgical Procedure
- Primary or type I fistula: It develops as a result of an underlying disease affecting gut.
- Example: Carcinoma colon infiltrating urinary bladder resulting in colovesical fistula or rupture through the skin resulting in pericolic abscess, fistula.
- Secondary or type II fistula: It occurs after injury to the otherwise normal gut. Examples: Left colonic/right colonic injury in percutaneous nephrolithotomy (PCNL) for renal stones or following anastomotic leak.
Depending upon the Site of the Fistula
- Lateral fistula: It occurs after a colocolic or ileocolic anastomosis wherein a few sutures would have given way in the immediate postoperative period.
- End fistula: This means both ends of the intestines are open following resection and anastomosis giving rise to postoperative peritonitis.
- A few fistulae in diverticular disease of the colon.
Faecal Fistula Bacterial Flora:
- More than 99% of faecal bacterial flora are anaerobic.
- The most common anaerobe is Bacteroides fragilis, with a count of 1010/g of wet faeces. Clostridia and Lactobacillus are other organisms.
- E. coli is the predominant aerobic organism. The count is 107/g of faeces. Klebsiella,
- Proteus, and Enterobacter are other aerobes. Streptococcus faecalis is the principal enterococcus.
Faecal Fistula Clinical Manifestations
- Postoperative patient ‘not doing well’—prolonged paralytic ileus, feculent discharge from wound or drainage site, etc. is an indication of faecal fistula.
- Features of septic shock: Often patients may not complain of abdominal pain but manifestations can be of renal failure, tachycardia, tachypnoea and hypotension.
Faecal Fistula Diagnosis:
- Total counts are elevated—it indicates infection.
- Creatinine and urea values are high indicating renal failure.
- Ultrasound to detect any collection.
- CECT can detect intraperitoneal collection, pneumoperitoneum, anastomotic leak. However, creatinine should be normal before doing a CT scan. Often patients are in sepsis with renal failure.
Types of Fistula Related to Diverticular Disease:
- Colovesical: 65%
- Colovaginal: 25%
- Colocutaneous
- Coloentera
Faecal Fistula Treatment:
Control of infection
- Drainage of sepsis—laparotomy, resection and anastomosis, ileostomy or colostomy may be necessary.
- Lateral fistula may heal with total parenteral nutrition provided there is no distal obstruction (TPN).
- End fistula may require resuturing with or without proximal diversion colostomy/ileostomy.
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