Intestinal Fistula Surgery Clinical Presentation

Updated: Sep 18, 2015
  • Author: Neelu Pal, MD; Chief Editor: John Geibel, MD, DSc, MSc, AGAF  more...
  • Print
Presentation

History and Physical Examination

The clinical presentation of the various forms of intestinal fistulas depends on the organs involved. The predominant signs and symptoms are those of infection from intestinal bacterial contamination.

Enterocutaneous fistulas

Excessive drainage via the abdominal incision or via operatively placed drainage catheters is often the first indicator of a postoperative enterocutaneous fistula. The drainage typically consists of obvious intestinal contents or fluid with bile staining (see the image below). The presence of purulent fluid may disguise the character of the intestinal fluids, leading to initial misdiagnosis of a wound infection. The presence of gas bubbles in the wound or drain output also indicates an intestinal connection. If differentiation proves difficult, the patient may be given oral methylene blue, indigo carmine, or activated charcoal. The presence of these substances in the drainage confirms the presence of an intestinal leak.

Enterocutaneous fistula. Enterocutaneous fistula.

The skin surrounding the area of the fistula is erythematous and indurated and may be fluctuant if an underlying collection is present.

Clinical signs of sepsis (eg, fever, tachycardia, chills) are common when the fistula is associated with undrained intraperitoneal abscesses and infection of the soft tissue of the abdominal wall.

Enteroenteric fistula

Radiologic studies are often used for initial diagnosis of enteroenteric fistulas. The studies are obtained to evaluate intestinal symptoms or abdominal pain. Diarrhea, abdominal pain, weight loss, and fever are common symptoms associated with enteroenteric fistulas of all etiologies.

Enteroenteric fistula symptoms are nonspecific and may be due to the underlying disease process (eg, Crohn enteritis, radiation enteritis) or the presence of the fistula. Abdominal tenderness may be present on physical examination. Occasionally, a palpable abdominal mass representing densely adherent bowel loops is present.

Enterovesical fistula

Urinary tract contamination with intestinal organisms leads to the development of urinary symptoms in more than 80-90% of patients with enterovesical fistulas. The common presenting urinary symptoms include bladder irritability, dysuria, pyuria, fecaluria, and pneumaturia. Fulminant urosepsis may develop, especially in patients who are immunocompromised from underlying disease or immunosuppressant medications. (See the image below.)

Enterovesical fistula. Enterovesical fistula.

Nephroenteric fistulas

Typically, nephroenteric fistulas (see the image below) develop slowly because of chronic renal disease; thus, the most common initial symptom is chronic urinary tract infection. In contrast, nephroenteric fistulas that occur from penetrating trauma often present early with symptoms of urinary tract infection.

Nephroenteric fistula. Nephroenteric fistula.

Patients may have flank pain, tenderness, and a mass. As the fistula becomes established, fecaluria, pneumaturia, fever, chills, and fulminant sepsis develop. A watery diarrhea can occur, and, in the late stages, severe dehydration, uremia, and acidosis develop. Function of the affected kidney is rarely normal. Perinephric abscesses are common and may cause a mass effect, leading to further deterioration of function.

Enterovaginal fistulas

Purulent or feculent vaginal discharge is the most common presentation of enterovaginal fistula (see the image below). Sepsis from associated intraperitoneal abscesses is common, and these patients experience abdominal pain, fever, and chills. Patients may develop a urinary tract infection because of bacterial contamination ascending the urethra.

Enterovaginal fistula. Enterovaginal fistula.

Aortoenteric fistula

Aortoenteric fistulas (see the image below) present with gastrointestinal (GI) bleeding because of a direct communication between enteric lumen (commonly duodenum and the arterial lumen). Initial herald or sentinel bleeding (eg, hematemesis, hematochezia, melena) is commonly mild and self-limited. Often weeks to months later, the patient has an episode of massive GI hemorrhage.

Aortoenteric fistula demonstrating a direct connec Aortoenteric fistula demonstrating a direct connection between the intestinal lumen (typically the duodenum) and the prosthetic graft.

Patients with a paraprosthetic-enteric fistula (see the image below) have a perigraft abscess or an aneurysm that communicates with the intestinal lumen. Sepsis and abdominal pain are observed on initial presentation. If the infection remains untreated, eventually a communication develops between the arterial and intestinal lumen and GI hemorrhage occurs.

Aortoenteric fistula that forms through erosion of Aortoenteric fistula that forms through erosion of a periprosthetic graft infection into the intestinal lumen.

Subclinical ongoing bleeding leads to chronic anemia. A patient with an aortic prosthetic graft and evidence of either acute or chronic GI hemorrhage must have an aortoenteric fistula unless definitive proof to the contrary is available.