A client with an Enterocutaneous Fistula

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A client with an Enterocutaneous Fistula Essay

A fistula is an untypical connection between two epithelialized surfaces; an enterocutaneous fistula, as the name stipulates, is an abnormal communication between the large or small bowel and the skin. As a result, contents of the intestines or stomach leak through to the skin. The fistula can arise from the jejunum, ileum, duodenum, rectum, or colon, which mostly occurs after bowel surgery. Other causes of enterocutaneous fistula include perforated peptic ulcer, infection, and inflammatory bowel diseases such as ulcerative colitis or Crohn’s disease. Similarly, an enterocutaneous fistula may also develop as a result of trauma or an abdominal injury, such as a gunshot or stabbing. Therefore, it is not only as a result of a colon or intestinal infection but also as a result of chronic inflammation of the withers of a horse.

According to Gibovskaja and Melton (2016), clients with enterocutaneous fistula are those patients that have been diagnosed with this particular infection. Often, such patients experience complex problems that require long-term care. A client with an Enterocutaneous Fistula Essay.For instance, the problem of malnutrition requires the consistent provision of a balanced diet to such patients in order to increase the patient’s healing process. However, when such provisions are not provided, the patient may suffer from malnutrition, which may lead to the death of the patient. Similarly, the problem of increased diarrhea and dehydration will also require long-term care.

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After diagnosis, the patient is objected and exposed to a Complex Abdominal Surgery Program, which is a high-volume service whose surgeons perform a challenging and intricate abdominal procedure using a modern surgical repair. According to Mishra and Firodous (2018), the use of the program has not only helped towards the treatment of enterocutaneous fistula patients but has also saved the lives of many. Other multidisciplinary teams that work hand in hand with surgeons also include specialists in intensive care medicine, nursing, plastic surgery, pharmacology, infectious diseases, nutritional, wound care, and physical rehabilitation. The experiences from the surgeons and a multidisciplinary team help ensure that each enterocutaneous fistula patient receives the best care.

Signs and symptoms of clients with an Enterocutaneous Fistula

Enterocutaneous Fistula patients develop different signs and symptoms, just like any other patient suffering from a particular kind of disease. For instance, the fistula can cause the contents of the stomach and the intestines to leak through an opening in the skin. It also can cause dehydration where water is seen moving out of fistula patient individual cells and then out of the body than the amount of water taken in through drinking. Here, the patient is seen sweating a lot to the extent of some of them fainting.

Similarly, fistula can also cause diarrhea to the patient, where the patient is seeing visiting the toilets frequently. During diarrhea, the patient’s feces are discharged from the bowels frequently and in a liquid form. Luckily, diarrhea is usually short-lived, but when it persists, one can easily presume that such a client is suffering from a fistula. A client with an Enterocutaneous Fistula Essay. Nevertheless, a fistula may cause malnutrition where the body of the patient doesn’t get enough nutrients to the extent that even if the patient is subjected to a balanced diet, he still continues to suffer from dizziness, fatigue, and weight loss. When such a condition is not taken care of, the patient may suffer from a physical or mental disability.

Diagnosis

During the diagnosis of a patient with fistula, the patient’s doctor conducts a thorough physical exam and may order for the following tests to confirm the detection of enterocutaneous fistula. The tests include an abdominal CT scan, which involves the use of x-rays to generate cross-sectional pictures of the belly area. During the test, the patient is made to lie on a table that slides into the CT scanner. Once the patient is inside the scanner, the x-ray machine rotates around the patient for about thirty minutes and, thereafter, get the results of what the patient may be suffering from.

Secondly, according to Velásquez-Rodríguez and Fernández-Avilés (2018), the doctor may prescribe a barium enema test to be conducted, if the fistula involves the colon and rectum. This test may be done in a hospital radiology department or a doctor’s office, especially when the colon of the patient is completely empty and clean. However, when the patient’s colon is not empty and clean, the doctor will give instructions to the patient for cleansing his colon.

Thirdly, the test of an esophageal, also called a barium swallow, might also be prescribed by the doctor. This test involves a series of X-rays of the esophagus. During this test, the patient is subjected to drinking a liquid containing barium, which coats the inside of the patient’s esophagus. The barium causes changes in the appearance of the esophagus to appear on the X-rays. Similarly, the doctor may suggest a test of a Fistulogram to be conducted to the patient with fistula. This test involves taking X-rays and injecting contrast dye into the opening of the skin of an enterocutaneous fistula client. A client with an Enterocutaneous Fistula Essay.

Treatment

Yilmaz and Hetzer (2011) suggest that most of the patients with fistula who follow the treatment procedures which consist of its identification, followed by widespread supportive care with electrolyte and fluid replacement, control of pyemia, sustenance support and control of fistula drainage by pharmacologic often get treated from this infection. The treatment does not only bring smiles and good health to the patients but also frees them from enterocutaneous fistula infection. However, if the enterocutaneous fistula doesn’t cure on its own after a few days or weeks, complex surgery is needed to close the fistula and reconnect the intestinal tract. Since patients with fistula often need specialized nutritional rehabilitation, wound care, and physical rehabilitation, specialists in nutrition, nursing, wound care, intensive-care medicine, plastic surgery, and pharmacology are often involved in the successful treatment of the enterocutaneous fistula patients. At the University of California, San Francisco (UCSF) research institutions, enterocutaneous fistulas are treated by experts in the Complex Abdominal Surgery Program.

Conclusion

Enterocutaneous Fistula remains a complex issue that is optimally managed using an interdisciplinary and a careful approach. In addition to primary management of toxemia, conventional treatment remains the treatment mainstay, including the combination of social support, wound management, and nutritional support with PN or EN sometimes in combination. A client with an Enterocutaneous Fistula Essay. Therefore, surgical treatment with resection should be carefully designed for use in cases that conservative treatment fails.

References

Gribovskaja-Rupp, I., & Melton, G. B. (2016). Enterocutaneous fistula: proven strategies and updates. Clinics in colon and rectal surgery, 29(02), 130-137.

Mishra, J., Firodous, A., & Mishra, B. (2018). Rationale in management of entero-cutaneous fistula following routine and emergency surgery: a prospective study in a tertiary care hospital of Odisha. International Surgery Journal, 5(12), 4000-4006.

Velásquez-Rodríguez, J., Zatarain-Nicolás, E., Barrio, J. M., Ruiz-Fernández, M., Valerio, M., & Fernández-Avilés, F. (2018). Enterocutaneous Fistula After Heart Transplant: A Consequence of a Left Ventricular Assist Device. Revista Española de Cardiología (English Edition).

Yilmaz, K., Erpenbeck, H., Drews, T., & Hetzer, R. (2011). Small bowel fistula and its impact: incorrect placement of left ventricular assist device cannulas leads to severe intestinal complications. Case Reports, 2011, bcr0320114003.

Enterocutaneous fistulas represent a challenging situation with respect to wound care and stoma therapy. An understanding of the principles of wound care and the various techniques and materials that are available is of vital importance to enhance patient comfort and recovery as well as facilitate fistula healing. Skin barriers, adhesives, dressings, pouches, and negative pressure dressings are all materials that are available in the armamentarium of the enterostomal therapist. Proper utilization of these items and appropriate modifications to their application requires an intimate knowledge of the characteristics of the fistula being treated. A client with an Enterocutaneous Fistula Essay. Wound care management is a key element in the overall care and healing of the enterocutaneous fistula.

Keywords: Enterocutaneous fistula, wound management, skin barriers, pouches, negative pressure dressings
Wound care management of the enterocutaneous fistula (ECF) is one of the greatest challenges in the surgical patient and can present a complex problem for the clinician. ECFs represent a demanding situation in terms of their management that often requires a multidisciplinary approach to facilitate patient care and fistula healing. Medical, surgical, nutritional, and enterostomal wound care services are frequently involved each with a vital role. By definition, a fistula is an abnormal, epithelialized connection between two body structures and can occur anywhere surgical wounds occur.1 Fistulas in the gastrointestinal (GI) system are classified according to site of origin and termination, volume and type of drainage, and etiology. An ECF is an epithelialized connection from the intestine to the skin.

An ECF may occur either spontaneously or related to surgery. It is estimated that ∼80% of ECFs occur as complications of abdominal surgery with an overall incidence of 0.8 to 2%.2 Most ECFs occur in the postoperative setting and are commonly associated with malnutrition and postsurgical sepsis. An ECF as a result of surgery can be seen related to cancer, inflammatory bowel disease, Crohn’s disease, trauma, or lysis of adhesions. The fistula may develop as a result of breakdown of the primary anastomosis or an unidentified injury to the bowel during surgery. A spontaneous fistula can be associated with diverticular disease, ischemic bowel, perforated ulcerations, or appendicitis.3 Regardless of the initiating event that leads to formation of an ECF, management and control of the wound can be very difficult.

The most demanding aspects of the ECF are skin protection, drainage quantification, and drainage containment to prevent additional skin damage secondary to the corrosive effluent surrounding the aperture.4 The effects of continuous moisture from the ECF can severely damage the surrounding skin and risk development of infection. In addition, the effluent acts as a chemical irritant, depending on the origin of the fistula, and can compromise skin integrity. These factors pose significant problems in wound care related to the ECF and can be very difficult to manage. A client with an Enterocutaneous Fistula Essay.

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GOALS
An effective ECF wound care management plan should achieve the following goals.5Ideally, the goals can be achieved simultaneously, but prioritization may be necessary based on the individual patient with the ECF:

Skin protection

Patient comfort and mobility

Containment of drainage and odor

Accurate measurement of effluent

Cost containment

Skin Protection
Skin protection and prevention of further skin breakdown surrounding the ECF are key components in wound care. There are several causes of impaired skin integrity at the site of the ECF. The four most common causes are mechanical trauma, allergic responses, infections, and chemical irritants.6 Frequent dressing changes due to adhesives and pouching methods can contribute to the breakdown of the surrounding skin causing repeated mechanical trauma and prevent proper healing. Allergic reactions to the dressing or pouch materials may cause erythema, edema, or weeping skin, which can become more susceptible to infection. Infections secondary to entrapment of exudates against the skin, namely fungal, can result in chronic skin infections with erythema, papule and vesicle formation. A client with an Enterocutaneous Fistula Essay.

The most common chemical irritant is bowel contents. The enzymatic contents of the effluent are many times more detrimental to the skin integrity than the actual volume of the effluent. More proximal ECFs contain proteolytic digestive enzymes, which further damage the surrounding skin by entrapment, leaking and persistent moisture, which in turn jeopardizes skin integrity and healing. These digestive secretions exhibit a toxic effect on living tissue and correlates with our clinical observations that fistula effluent does indeed inhibit wound healing.7 Healing the surrounding skin, preventing further skin breakdown, and minimizing contamination are key components in the wound management of these patients and are of paramount importance. Without this, a futile cycle develops in which skin breakdown leads to failure of pouch adherence, further leakage, and worse skin maceration.

Patient Comfort and Mobility
Skin irritation and discomfort can seriously affect the patient if the wrong management technique is used. Certain pouches and/or appliances with the use of belts can help minimize and prevent unnecessary patient discomfort, which is a key psychosocial component of wound management in these patients. Ambulatory patients should not be restricted in their recovery and mobility should not be compromised by a wound management system. Therefore, individualization is an important part in devising the best care for a patient with an ECF.

Containment of Drainage and Odor
Drainage containment is a key essential to improving the surrounding skin integrity. Enteric contents can spill onto the surrounding skin leading to persistent tissue inflammation and infection, which if left untreated, can develop into sepsis. Containment of the effluent can be accomplished with pouching devices, suction devices, dressings or a combination of these management techniques. Dressing material that absorbs and retains caustic secretions is thought to be a major contributor in the delay of healing of ECFs. A client with an Enterocutaneous Fistula Essay. Therefore, continuous suction devices or stoma application has been advocated as an adjunct to wound care and skin preservation.8However, the patient’s overall clinical status may play a role in devising the best solution for that individual patient.

Though not commonly addressed, persistent odor from the ECF can be a tremendous source of anxiety and social concern for these patients. Odor control is best controlled with the use of a pouch. Most pouches have an odor-proof film and both internal and external deodorants are available and can help with odor elimination. Deodorants are available in tablet, liquid, or powder forms. There are certain medications that can be taken that may help with odor control including chlorophyll tablets, bismuth subgallate, and bismuth subcarbonate. In addition, special deodorizers can be placed in the pouch to assist with odor control such as 3% hydrogen peroxide and Hollister M9 odor-eliminating drops.

Accurate Measurement of Effluent
Measurement of the fluid and electrolyte balances in these patients is another important goal in wound care of the ECF patient. Leakage around catheters can give an inaccurate reading of actual fluid losses. Dressings can also give an inaccurate reading unless the dressings are weighed on a regular basis. These factors must be taken into account during wound management of ECF patients. Especially with short bowel and proximal ECFs, fluid losses can be up to multiple liters daily. Concomitant electrolyte abnormalities can lead to secondary effects ranging from cardiac arrhythmias to renal failure. Accurate measurement of the effluent is essential to help guide the fluid and nutritional needs in these often sick patients. A client with an Enterocutaneous Fistula Essay.

Cost Containment
Cost-effective medical care is also a principal component in the wound care of patients with ECFs. Attention must be applied not only to the products and materials used for wound care, but labor and time must also be considered. Hospital costs for ECFs are considerable and the average length of stay varies widely.9 In a critically ill patient with an ECF, costs can average approximately $10,000 per day.5 Skin care rituals that consume excessive time and expense without resulting in optimal patient outcomes must be eliminated. Therefore, cost containment is another essential goal in the treatment of ECF patients.

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ASSESSMENT
The initial step after identification of an ECF consists of an overall assessment of the patient, nature of the fistula, and condition of the associated wound. Evaluation for infection and/or sepsis, electrolyte imbalances and nutritional needs are also crucial.

This assessment includes four factors that must be individualized for each ECF patient: (1) origin of the fistula tract, (2) location of the fistula opening at skin level, (3) type of effluent (i.e., enzyme and electrolyte constitution), and (4) skin integrity.

Origin of the Fistula Tract
First, identification of where the fistula is communicating with the bowel aids in the management of the wound. The location of the origin of the fistula is paramount to providing good wound care and healing of the surrounding skin. A client with an Enterocutaneous Fistula Essay. It has been identified that the small bowel is the most common site of origin in ECFs (Table 1).10 The enteric contents from the small bowel can be more challenging to deal with compared with colonic-cutaneous fistulas based on characteristics and type of effluent alone.

Table 1
Site of Origin of Enterocutaneous Fistulas

Fistula Location Number of Fistulas %
Adapted from Draus et al.10
Stomach 8 7.6
Duodenum 5 4.7
Small bowel 67 63.2
Colon 26 24.5
Total 106 100
Diagnostic studies can be used to help identify the location of origin of the fistula and therefore help plan wound care and/or stoma therapy. Although covered in depth by Drs. Lee and Stein in this issue, contrast studies, computed tomography scans, fistulograms, and even methylene blue can be used to provide anatomic information about the source, length, course and other characteristics of the ECF.11 Importantly, if diagnostic studies are not available, insight into the origin of the fistula can often be identified based on examining effluent characteristics alone. Odor, color, consistency, type and amount of effluent, and the effect on the surrounding skin can be used to determine the origin of the fistula. The fistula effluent can also be sent for laboratory analysis to determine the chemical make-up that may also give additional clues. A client with an Enterocutaneous Fistula Essay.

Location of the Fistulous Opening at the Skin Level
The location of the fistulous opening on the skin plays a significant role in wound management, product selection, and skin care. Identification of the aperture in relation to skin folds, bony structures (i.e., costal margin, anterior superior iliac spine), and open wounds play a key role in devising the best system for each individual patient. Irregular skin surfaces and defects may need to be corrected with skin barriers (covered below). In addition, convexity of the wound in relation to the skin surface needs to be taken into account for wound care, pouch selection, and devising an appropriate management system.

Single versus multiple openings may also play a factor in choosing the best route for wound care and management. Multiple fistulas in close proximity may be addressed with a single management technique. Widely spread fistulas, on the other hand, may need to be addressed separately and pouched or dressed separately. In addition, normal skin bridges should always be evaluated to determine size, condition and method of handling. Consideration in small bridges should be given for either proper protection versus opening to unify multiple adjacent openings into one area.

Type of Effluent
Characteristics of the ECF effluent can help to identify the source of the fistula if no diagnostic studies are available. The amount and nature of the effluent is a key factor in determining skin care methods and materials used to protect the surrounding skin. A high-output fistula is defined when the output is greater than 500 mL/d, moderate when the volume is 200 mL to 500 mL/d, and low when the output is less than 200 mL/d.12 If the fistula is considered a high-output fistula, then a pouching system may be more appropriate for that patient. A client with an Enterocutaneous Fistula Essay. If the output is low, then a simple skin barrier and/or dressing may be more appropriate. As evidence of this, patients with long-standing end colostomies technically have an ECF that, through a well-rehearsed bowel regimen, are often able to simply cover the stoma with a gauze bandage in between bowel movements.

The caustic nature of the effluent will also play a role in determining which skin care materials to use. More enzymatic effluent may require a pouching or suction device to divert the effluent from the surrounding skin and prevent further skin breakdown.

Skin Integrity
Assessment of the skin integrity around the fistula is also important. The initial condition of the surrounding skin is critical in determining the type of skin materials to be used in the wound management of these patients. If the skin is relatively healthy, skin barriers and other means to prevent any breakdown are essential. In most instances, the skin surrounding the fistula is denuded, either from the nature of the effluent or the constant presence of moisture, and therefore a management technique to heal and prevent further damage is crucial to the healing process. If the skin has either erythema or skin loss due to repeated trauma to the wound, then more aggressive skin care is necessary. Skin that is ulcerated or infected can be the most difficult wound to treat in the ECF patient. A client with an Enterocutaneous Fistula Essay.

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MANAGEMENT
The materials selected for the wound care of the ECF patient depends on the characteristics of the fistula such as output, type of drainage, location, and perifistular skin integrity. Materials include skin barriers; adhesives; dressings, pouches and wound managers; and negative pressure dressings such as vacuum-assisted closure (V.A.C.; Kinetics Concepts Inc., San Antonio, TX).5,13,14

Skin Barriers
ECFs can often represent very difficult situations with respect to skin protection. Depending on the origin location of the fistula in the GI tract, fistula output could be acidic, alkaline, or contain proteolytic enzymes, all of which could be damaging to skin. As previously stated, the enzymatic nature of the effluent is more damaging to the skin than the actual volume.

Skin barriers are the mainstay in fistula management with respect to skin protection by forming physical barriers between effluent and the skin surface. Skin barriers are available in various forms; they include solid wafers, powder, paste, and sealants.

Solid wafers are pectin-based products that have their own adhesive surface.14 This surface melts on contact with the patient’s warm skin and creates a seal thereby protecting the skin from direct contact with the effluent. A client with an Enterocutaneous Fistula Essay. Wafers are changed only when they loosen from wound edges or melt out. Additional sheets of wafer can be used to increase or build up the area available for adhesion.

Skin barrier powders are used in fistulas with associated skin wounds that are wet and weeping.5 Barrier powders [available from numerous manufacturers such as Hollister (Hollister, Inc., Libertyville, IL) and Coloplast (Humlebaek, Denmark)] are pectin or karaya-based, and are used to absorb the moisture and create a dry surface for subsequent dressing or pouch application. A thin layer of powder is applied to the denuded skin and allowed to dry before application of the barrier wafer or adhesive surface of a pouch system. Care must be taken not to apply excessive amounts of powder. These powders should be discontinued once the denuded skin is intact and re-examination of the wound performed.

Skin barrier pastes are used to reinforce the inner edges of solid wafers to protect them from melt out and establish an improved seal. Pastes may also be used to smooth out irregularities in perifistular skin to create a flat surface for wafer application. This is crucially important in obese patients where skin surface irregularities and folds may severely limit proper pouching (Fig. 1).

Figure 1
Obese ostomy patient with multiple skin folds.

Finally, skin sealants are used to protect the skin surface from adhesives and to create a tacky surface for improved adherence of pouches such as 3M Cavilon no-sting barrier (3M, St. Paul, MN). Sealants are also used to seal in powders on denuded skin surfaces and facilitate pouch placement. Skin sealants often contain alcohol and therefore can only be placed on intact skin. Sealants are available in numerous forms including wipes, sprays, gels, or brush-on liquid.

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Adhesives
Adhesives are used to enhance or extend another product’s adhesive surface or attach two surfaces when modifying a fistula collection system. Mobile and flaccid skin seems to benefit in particular from adhesive use to improve the seal and increase the wear time of a pouching system. A client with an Enterocutaneous Fistula Essay. Adhesives are available in three forms: liquid, aerosol, and double-faced adhesive sheet or disc. Liquid and aerosol adhesives contain solvents and must be applied slowly and evaporate before application of any additional products. Sheets of adhesives or double-faced adhesive discs can be used to create or increase the adhesive surface of a pouch when unusually shaped pouch apertures are required.

Dressings
Dressings are readily available and easy to implement for the appropriate patient. They provide a cost-effective method of wound care for simple ECFs and/or low-output fistulas, less than 200 mL/d. Overlying gauze dressings in combination with skin barriers can be used to effectively contain and manage ECF effluent. However, if fistula output is considered moderate or high or the dressings are being changed more frequently than every 4 hours, a pouching system should be implemented. In this instance, frequent dressing changes become impractical and do not offer the ability to accurately record fistula output. In addition, frequent tape changes associated with dressings can also jeopardize skin integrity especially in the setting of already compromised skin due to effluent-induced irritation.

Pouches
As mentioned earlier, one of the main goals of fistula management is drainage control and containment. Drainage control is very important as continued contact of effluent with the skin surface can lead to maceration and increased likelihood of breakdown and perifistular skin infection, namely fungal. Depending on the volume of drainage, this can be accomplished in a variety of manners. A client with an Enterocutaneous Fistula Essay.

Since the advent of enterostomal therapy (ET) nursing at the Cleveland Clinic in the 1950s, many draining wounds and fistulas have been managed with ostomy pouches. Effective pouching of a fistula can achieve all the goals of fistula management and various ostomy pouches are available today. The choice of pouch system to be used depends on the characteristics of the fistula being managed. Generally, high-output fistulas with very thin liquid effluent are best managed with pouches that have a urinary outlet system or spigot to allow for easy drainage and emptying.

Continuous drainage can be achieved with urinary outlet pouches by attaching drainage tubing to the urinary spigot. This can greatly enhance nursing efficiency by minimizing the need for pouch emptying and prevents pouch overfilling in situations where fistula output is very high. Alternative pouch outlets include fecal outlets with a drainable clip that is appropriate for fistulas with 24-hour outputs less than 1000 mL and wide tubular outlets or wound managers. A client with an Enterocutaneous Fistula Essay.