Enterocutaneous Fistula Clinical Presentation

Updated: Apr 27, 2022
  • Author: Vikram Kate, MBBS, MS, PhD, FACS, FACG, FRCS, FRCS(Edin), FRCS(Glasg), FFST(Ed), FIMSA, MAMS, MASCRS; Chief Editor: John Geibel, MD, MSc, DSc, AGAF  more...
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History and Physical Examination

Features suggestive of an enterocutaneous fistula (ECF) include postoperative abdominal pain, tenderness, distention, enteric contents from the drain site, and the main abdominal wound. Tachycardia and pyrexia may also be present, as may signs of localized or diffuse peritonitis, including guarding, rigidity, and rebound tenderness.

The type of ECF, as based on the output of the enteric contents, also determines the patient's health status and how the patient may respond to therapy. ECFs are usually classified into three categories, as follows [3] :

  • Low-output fistula (< 200 mL/day),
  • Moderate-output fistula (200-500 mL/day)
  • High-output fistula (>500 mL/day)


Patients with ECF present with associated complications, such as sepsis, fluid and electrolyte abnormalities, and malnutrition.

The degree of sepsis depends on the state of the ECF. If the fistula forms a direct tract through which the bowel contents are draining onto the skin, then the sepsis may be minimal, whereas if the fistula forms an indirect tract through which the bowel contents are draining into an abscess cavity and then onto the skin, the degree of sepsis may be higher. In the presence of extensive peritoneal contamination or generalized peritonitis with ECF, the patient can be toxic as a consequence of severe sepsis.

Leakage of protein-rich enteric contents, intra-abdominal sepsis, or electrolyte imbalance–related paralytic ileus, as well as a general feeling of ill health, leads to reduced nutritional intake by these patients, resulting in malnutrition. Nearly 70% of patients with ECFs may have malnutrition, and it is a significant prognostic factor for spontaneous fistula closure. [15]

Sepsis, malnutrition, and electrolyte imbalance are the predominant factors that lead to death in patients with ECF. [16] Rarely, intestinal failure can occur as one of the complications of ECF, which results in significant morbidity and mortality. [17]

A high-output fistula increases the possibility of fluid and electrolyte imbalance and malnutrition.