Intestinal Fistulas Clinical Presentation
- Author: David E Stein, MD; Chief Editor: Julian Katz, MD more...
History and Physical Examination
Symptoms caused by fistulas that involve 2 segments of the bowel vary depending on the location of the fistula and the amount of bowel bypassed. For this reason, enteroenteric fistulas in which only a short segment of bowel is bypassed may be asymptomatic and diagnosed incidentally based on imaging findings or during surgery. Conversely, ileosigmoid fistula may cause diarrhea, weight loss, or abdominal pain.
Patients with gastrocolic fistulas may present with symptoms of abdominal pain, weight loss, and feculent belching.
Enterovesical and colovesical fistulas are easier to diagnose in patients who present with symptoms of pneumaturia, fecaluria, and recurrent urinary tract infections.
Patients with rectovaginal and anovaginal fistulas may be asymptomatic and present with symptoms only when the bowel movements are more liquid. Possible symptoms include inadvertent passage of stool or gas, dyspareunia, and perineal pain.
Patients with external fistulas generally present with symptoms of drainage through the skin. Patients with aortoenteric fistulas may report rectal bleeding.
Fluid or stool output through the skin, diarrhea, abdominal tenderness, weight loss, signs of malnutrition, and electrolyte imbalances are all possible findings in patients with fistulas.
Rectal bleeding may be a finding in patients with a history of radiation therapy. Hypotension and rectal bleeding may occur in patients with aortoenteric fistulas.
Elliott TB, Yego S, Irvin TT. Five-year audit of the acute complications of diverticular disease. Br J Surg. 1997 Apr. 84(4):535-9. [Medline].
Berry SM, Fischer JE. Classification and pathophysiology of enterocutaneous fistulas. Surg Clin North Am. 1996 Oct. 76(5):1009-18. [Medline].
Kyle J, Lee ECG, Nolan DJ. Fistulae in Crohn’s Disease. Clinical Surgery International: Surgery of Inflammatory Bowel Disorders. 1987. Vol 14:190-6.
Annibali R, Pietri P. Fistulous complications of Crohn's disease. Int Surg. 1992 Jan-Mar. 77(1):19-27. [Medline].
Lavery IC. Colonic fistulas. Surg Clin North Am. 1996 Oct. 76(5):1183-90. [Medline].
Donner CS. Pathophysiology and therapy of chronic radiation-induced injury to the colon. Dig Dis. 1998 Jul-Aug. 16(4):253-61. [Medline].
Böttger TC, Junginger T. Factors influencing morbidity and mortality after pancreaticoduodenectomy: critical analysis of 221 resections. World J Surg. 1999 Feb. 23(2):164-71; discussion 171-2. [Medline].
Falconi M, Pederzoli P. The relevance of gastrointestinal fistulae in clinical practice: a review. Gut. 2001 Dec. 49 Suppl 4:iv2-10. [Medline].
Pontari MA, McMillen MA, Garvey RH, et al. Diagnosis and treatment of enterovesical fistulae. Am Surg. 1992 Apr. 58(4):258-63. [Medline].
Rots WI, Mokoena T. Successful endoscopic closure of a benign gastrocolonic fistula using human fibrin sealant through gastroscopic approach: a case report and review of the literature. Eur J Gastroenterol Hepatol. 2003 Dec. 15(12):1351-6. [Medline].
Hancock BD. ABC of colorectal diseases. Haemorrhoids. BMJ. 1992 Apr 18. 304(6833):1042-4. [Medline].
Rolandelli R, Roslyn JJ. Surgical management and treatment of sepsis associated with gastrointestinal fistulas. Surg Clin North Am. 1996 Oct. 76(5):1111-22. [Medline].
Pederzoli P, Bassi C, Falconi M, et al. Conservative treatment of external pancreatic fistulas with parenteral nutrition alone or in combination with continuous intravenous infusion of somatostatin, glucagon or calcitonin. Surg Gynecol Obstet. 1986 Nov. 163(5):428-32. [Medline].
Wedell J, Banzhaf G, Chaoui R, et al. Surgical management of complicated colonic diverticulitis. Br J Surg. 1997 Mar. 84(3):380-3. [Medline].
Levy C, Tremaine WJ. Management of internal fistulas in Crohn's disease. Inflamm Bowel Dis. 2002 Mar. 8(2):106-11. [Medline].
Goverman J, Yelon JA, Platz JJ, et al. The "Fistula VAC," a technique for management of enterocutaneous fistulae arising within the open abdomen: report of 5 cases. J Trauma. 2006 Feb. 60(2):428-31; discussion 431. [Medline].
Dorta G. Role of octreotide and somatostatin in the treatment of intestinal fistulae. Digestion. 1999. 60 Suppl 2:53-6. [Medline].
Rahbour G, Siddiqui MR, Ullah MR, et al. A meta-analysis of outcomes following use of somatostatin and its analogues for the management of enterocutaneous fistulas. Ann Surg. 2012 Dec. 256(6):946-54. [Medline].
Amiot A, Setakhr V, Seksik P, et al. Long-term outcome of enterocutaneous fistula in patients with Crohn's disease treated with anti-TNF therapy: a cohort study from the GETAID. Am J Gastroenterol. 2014 Sep. 109(9):1443-9. [Medline].
Greenstein AJ. The surgery of Crohn's disease. Surg Clin North Am. 1987 Jun. 67(3):573-96. [Medline].
Von Koperen PJ, Bemelman WA, Gerhards MF, Janssen LW, van Tets WF, van Dalsen AD, et al. The anal fistual plug treatment compared with the mucosal advancement flap for cryptoglandular high transsphincteric perianal fistula: a double-blinded multicenter randomized trial. Dis Colon Rectum. Apr 2011. 54(4):387-93. [Medline].
Butchberg B, Masoomi H, Choi J, Bergman H, Mills S, Stamos MJ. A tale of two (anal fistula) plugs: is there a difference in short-term outcomes?. Am Surg. Oct 2010. 76(10):1150-3. [Medline].
Zhu YF, Tao GQ, Zhou N, Xiang C. Current treatment of rectovaginal fistula in Crohn's disease. World J Gastroenterol. Feb 2011. 17(8):963f-7. [Medline].
Present DH, Rutgeerts P, Targan S, et al. Infliximab for the treatment of fistulas in patients with Crohn's disease. N Engl J Med. 1999 May 6. 340(18):1398-405. [Medline].
Ellis CN. Sphincter-preserving fistula management: what patients want. Dis Colon Rectum. Dec 2010. (53(12):1652-5. [Medline].
Lindberg E, Jarnerot G, Huitfeldt B. Smoking in Crohn's disease: effect on localisation and clinical course. Gut. 1992 Jun. 33(6):779-82. [Medline].
Meissner K. Late radiogenic small bowel damage: guidelines for the general surgeon. Dig Surg. 1999. 16(3):169-74. [Medline].
Practice parameters for treatment of fistula-in-ano--supporting documentation. The Standards Practice Task Force. The American Society of Colon and Rectal Surgeons. Dis Colon Rectum. 1996 Dec. 39(12):1363-72. [Medline].
Schecter WP. Management of enterocutaneous fistulas. Surg Clin North Am. Jun 2011. 91(3):481-91. [Medline].