Fistulas SAWA Summarizing Group by mikesanye

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Done by : laith al-nasan.
• Fistulas is an abnormal communication
  between tow epithelial or endothelial
• The World Health Organization estimates that
  approximately 2 million women have
  untreated fistula and that approximately
  100,000 women develop fistula each
  year. Fistula is most prevalent in sub-
  Saharan Africa and Asia .
• Symptoms of fistulas can include pain,
  fever, tenderness, itching, and generally
  feeling poorly. The fistula may also drain
  pus or a foul-smelling discharge. These
  symptoms vary based on the severity and
  location of the fistula.
               Types of fistulas
• Congenital ( e.g. oesophageal atresia with a fistulous
  communication with the trachea)
• Acquired : - external fistulas involve the
             skin (e.g. enterocutaneous)
             - internal fistulas affect adjacent
              organs contiguously or more
              through an intervening
               abscess cavity (e.g. entro-
• Arteriovenous fistulas are an abnormal communication
  between an artery and a vein it could be :
              - congenital
              - acquired :
                           *iatrogenic ( for hemodialyisis )
• Various types of fistulas include:
• Blind: with only one open end
• Complete: with both external and internal
• Incomplete: a fistula with an external skin
  opening, which does not connect to any
  internal organ
    Internal abdominal fistulas
• Internal abdominal fistulas :Majority result
  from an underlying gastro-
   intestinal disease ( e.g. colonic
  diverticular disease, crohn’s disease,
  colonic carcinoma, radiation enteritis
  ,intestinal tuberculosis , chronic
  cholecystitis , etc )
   External abdominal fistulas
• External abdominal fistulas arise as a
  complication of surgery or to the
  trauma to the intra-abdominal organs
  such as anastomotic leakage , accidental
  or unrecognized injury during operation
• Other external fistulas are due to primary
  abscess formation which involve bowel
  and skin and these are best exemplified by
  the perianal fistulas
• In end stage renal failure patients,
  a cimino fistula is often deliberately
  created in the arm by means of a
  short day surgery in order to permit
  easier withdrawal of blood for
• As a radical treatment for portal
  hypertension (anastomosis
  between the hepatic portal vein
  and the inferior vena cava). This
  spares the portal venous system
  from high pressure which can
  cause esophageal varices, caput
  madusae, and hemorrhoids
• The effect of internal abdominal fistulas
  depend on :
•      - site.
        - pathology of the condition causing it.
• E.g. :- malabsorption and steatorrhoea may
  occur with entero-enteric and enterocolic
         - severe cystitis with pneumaturia may
  be caused by vesicocolic fistula etc.
• Constitutional effects are minimal with external
  colonic fistulas
• Malnutrition and fluid and electrolyte depletion
  accompany high output bowel fistulas
• Skin excoriation and digestion of the abdominal
  wall is a serious feature of pancreatic ,
  duodenal and high small bowel fistulas
• Healing of external abdominal fistulas can
  be expected if there is no distal obstruction
  to the involved bowel , the healing depend
  on :
   - adequate drainage of any abscess
  - the maintenance of a good nutritional
            Biliary fistulas
• External which are secondary to bile duct
  trauma or leakage or accessory bile ducts
  and gallbladder bed
• internal which are classified into three
  types : bilio-enteric, broncho-biliary and
  bilio-pleural, bilio-biliary
           Pancreatic fistulas
• May be internal or external and carry a
  substantial morbidity from sepsis, hemorrhage
  and persistent pancreatitis
• An external fistula may be secondary to a
  pancreatic abscess complicating acute
  pancreatitis, but may also follow abdominal
  trauma and operative intervention
• An internal pancreatic fistula is almost always
  due to a pancreatic abscess which complicates
  acute pancreatitis in 1-5 % of patients
    Gastrocutaneous fistulas
• These are usually iatrogenic following
  unrecognized operative injuries during
  splenectomy or vagotomy
• A small percentage are caused by benign
  gastric ulcer, pancreatic abscess and
  pancreatic carcinoma
         Small-bowel fistulas
• The majority (80-90 %) of small bowel fistulas
  follow operations on the intestinal tract either
  from anastomotic leakage or iatrogenic injury
• Often the anastomotic dehiscence is attributed
  to the presence of underlying small bowel
  disorder, crohn’s disease being the most
  common, but radiation enteritis and intestinal
  tuberculosis featuring often in several
  published series
      External colonic fistula
• These most commonly follow colonic
  surgery, including colostomy closure
• Trauma accounts for some cases as does
  perforated colonic diverticular disease
  and cancer
Colovesical and colovaginal fistulas
• The former is one of the commonest forms of
  internal abdominal fistulas
• Radiotherapy for malignant disease of the
  pelvis accounts for the majority of
  rectovaginal/vesical fistulas
• Both are usually encountered in association with
  diverticular disease and a pericolic abscess
  which perforates into the bladder or vagina.
• Crohn’s disease of the large and small bowel
  may be complicated by the development of
  entero/colovesical fistula
• Conservative :
  * the mainstays of medical management
  - nutritional support
  - meticulous collection of fistulous
- control of sepsis
       operative intervention
• Surgical :
 * the absolute indications for operative
  intervention are :
 - intestinal obstruction distal
 - peritonitis
 - abscess formation
 - bowel discontinuity
 - presence of malignant disease
 - persistent inflammatory bowel disease

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