Intestinal fistula – unnatural communication between a gleam of an intestinal tube and other bodies or skin. Internal fistulas often are shown for a long time by nothing. External fistulas come to light in the presence of the mouth on skin through which departs kalovy separated and gases, macerations of integuments around fistula. Also the progressing weight loss, the increasing polyorgan insufficiency can be noted. The diagnosis is made by means of radiological, endoscopic and laboratory researches, tests with dyes. Conservative treatment can be used in the presence of tubular fistulas and also as a stage of preparation for operation at spongy fistulas.
Intestinal fistula – heavy surgical pathology which frequency progressively increases as the total of inflammatory diseases of intestines most of which often lead to formation of unnatural communications increases. Allocate the congenital, acquired and artificially created forms of this disease (generally for an enteroalimentation or a decompression of intestines). The first operation on elimination of intestinal fistula was made in 1828, in the next years technology of surgeries was improved, vnebryushinny techniques of surgical treatment were developed. Today emphasis is placed on timely detection and conservative therapy of intestinal fistulas.
Reasons of intestinal fistula
The necrosis of an intestinal wall owing to local violation of blood circulation is the most frequent reason of formation of fistula. Inflammatory diseases (an acute appendicitis, a disease Krone, intestines diverticulums, cancer, actinomycosis, tubercular defeat of an intestinal tube) and violations of blood circulation and food of a wall of a gut (the restrained hernia, pathology of vessels of a bryzheyka) can lead to it. Formation of fistulas often happens against the background of the getting and stupid injuries of a stomach. As very common causes of maturing of the svishchevy course (to 70% of all cases) serve various postoperative complications: interloopy abscesses, peritonitis, intestinal impassability, insolvency of seams on an intestinal wall.
As more rare reason of formation of fistulas serve violations of an embryogenesis (a nezarashcheniye of a zheltochny channel, an atresia of disteel sites of intestines with emergence enterouterine, entero and anorektalny fistulas). It is rather rare pathology. In wartime as the reason of formation of intestinal fistulas the getting gunshot and missile wounds of abdominal organs prevail.
Formation of the svishchevy courses between intestines, other bodies and skin leads to heavy frustration in an organism. The main pathogenetic mechanisms of development of polyorgan insufficiency are connected with loss of a food himus, violation of absorption of nutrients, intoxication owing to inflammatory process in the field of the svishchevy course. In the predictive plan high fistulas of a small intestine are the most dangerous: on such svishchevy course within a day can stream about 10 liters of contents that leads to loss of considerable amount of liquid, digestive juice and enzymes, electrolytes and nutrients. Considerably the volume of the circulating blood decreases, there is a haemo concentration which is expressed increase in gematokritny number. Because of the expressed dehydration the volume of the blood circulating through tubules of kidneys decreases, the diuresis suffers. Kompensatorno raises production of an aldosteron who promotes intensive removal of potassium from an organism.
Absorption of nutrients in intestines also suffers. The covering of power inquiries of an organism at first occurs due to splitting of stocks of a glycogen in a liver and muscles, then catabolic processes with use of endogenous reserves of protein and fat join. Disintegration of cages at an excess catabolism leads to accumulation in an organism of potassium, toxic products of exchange that even more aggravates a renal failure as kidneys are responsible for removal of products of a catabolism from an organism. Exhaustion and polyorgan insufficiency which in 40% of cases can lead to the death of the patient develop.
Low tonkokishechny, and also tolstokishechny fistulas seldom lead to the expressed dystrophic changes in an organism. The bulk of nutrients and liquid is soaked up in the top departments of a small intestine therefore loss of intestinal contents at the level of disteel departments of a digestive tube does not lead to considerable dehydration, deficiency of nutrients and exhaustion. The greatest problem at low intestinal fistulas is represented by an atrophy mucous the taking-away department of intestines, increasing the frequency of postoperative complications in the future.
Classification of intestinal fistula
On an etiology distinguish the congenital and acquired intestines fistulas. Congenital forms represent no more than 2,5% of all cases, are usually connected with an underdevelopment of an intestinal tube or a nezarashcheniye entero a channel. Among the acquired intestinal fistulas about 50% occupy postoperative. Special group of the acquired forms of a disease artificially imposed openings for an enteroalimentation make, unloadings of intestines at peritonitis, intestinal impassability, gut tumors. As an immediate cause of formation of the svishchevy course can serve: emergence or progressing of the destructive inflammatory center; spontaneous opening of abscess of an abdominal cavity; a rupture of a loop of intestines in attempt of reposition of the restrained hernia; progressing of tumoral process with germination of a forward belly wall.
There is several morphological classification of this pathology. As the message distinguish the internal, external and mixed fistulas. Internal connect a gut cavity to other internals (a uterus, a bladder, other departments of intestines), external open on the surface of skin. The mixed svishchevy courses have an exit and in other bodies, and on skin. Also allocate the created and not created types. Carry the fistulas opening in a wound of a belly wall or a purulent cavity, and also not having the svishchevy course because of an increment of a mucous membrane of a gut to skin (gubovidny fistula) to not created. The created fistulas are characterized by existence of accurately issued svishchevy course covered by an epithelium (tubular fistula). Tubular can have the courses, various on length, width and a structure (direct or wavy), however diameter of the mouth is always less, than at spongy. Also fistulas can be single and multiple (on one loop of a gut, on different loops, in different departments of intestines).
Depending on an intestines contents passage fistulas can be full (all contents stream from intestines, without coming to the taking-away loop) and incomplete (contents of intestines arrive outside only partially). Full fistulas are often characterized by existence of an intestinal spur. The spur can be true (constant ineradicable protrusion of a wall of a gut opposite I whistle, in a cavity of an intestinal tube with overlapping of its gleam) and false (protrusion of a wall of a gut is mobile and removable). True spurs most often lead to formation of full gubovidny fistulas.
On character of separated distinguish kalovy intestinal fistulas, mucous, purulent and combined. Also in classification existence of complications is considered: local (inflammation, dermatitis, intestines eventration), the general (exhaustion, depression).
Symptoms of intestinal fistula
Clinical displays of intestinal fistulas to a great extent depend on their localization, morphological characteristics, emergence time. The created fistulas have more favorable current, usually are not followed by heavy general symptoms. Not created fistulas, even low, proceed against the background of intoxication due to inflammatory process in the field of the mouth of the svishchevy course.
Internal interintestinal fistulas can not be shown a long time in any way. In the presence of enterouterine, entero fistulas allocation of kalovy masses from a vagina, impurity a calla in urine is usually noted at an urination, inflammatory process of bodies of a small pelvis. High tonkokishechno-tolstokishechny fistulas are followed by rather expressed clinic: persistent diarrhea, gradual, but considerable loss of weight.
External fistulas also have the clinical features caused by localization. High tonkokishechny external fistulas are characterized by existence of defect on skin through which the yellow, foamy intestinal contents containing food , gastric and pancreatic juice, bile are plentifully allocated. Around the svishchevy course maceration, dermatitis quickly develops. Losses of liquid on high fistula of a small intestine considerable, lead to a gradual decompensation of the general state and development of polyorgan insufficiency. Loss of weight can reach 50%, the clinic of heavy exhaustion, a depression is gradually developed. Low fistulas of a thick gut proceed easier, they are not accompanied by big losses of liquid. Considering that kalovy masses in a large intestine is already created, the expressed maceration of skin and dermatitis also does not happen.
Carry to the most frequent complications of intestinal fistulas exhaustion, violations of water and electrolytic balance, sepsis, dermatitis, bleeding, loss of a mucous membrane of a gut in svishchevy the course.
Diagnosis of intestinal fistula
Consultations of the gastroenterologist and the surgeon are necessary for visual survey, a manual research of the svishchevy course. During clinical examination the fact of existence of the svishchevy course, its morphological characteristics is established. Correctly performed inspection of area of the svishchevy course will allow to appoint researches, necessary for confirmation of the diagnosis. For specification of localization of fistula the analysis of the bilirubin separated regarding existence in it, bilious acids, pancreatic enzymes can be required. Tests with dyes have also great clinical value. At suspicion of fistula of a small intestine methylene blue is allowed to drink, in the presence of fistula of a thick gut – entered in the form of an enema. Depending on time of emergence of dye in separated from the svishchevy course exact localization of fistula is also established.
For assessment of a condition of internals, their relationship with the svishchevy course ultrasonography of abdominal organs, a multislice spiral computer tomography of abdominal organs, a survey X-ray analysis of abdominal organs can be required. Also broad application was found by X-ray contrast techniques: a barium passage X-ray analysis on a small intestine, an irrigoskopiya, a fistulografiya (introduction of contrast in svishchevy the course).
Consultation of the endoscopist is necessary for carrying out EGDS, a fibrokolonoskopiya. When using these methods of a research the doctor has an opportunity to examine the internal mouth of fistula, to estimate a condition of a mucous membrane of intestines, to reveal a true or false spur.
Treatment of intestinal fistula
Treatment of patients with high tonkokishechny fistulas is carried out in intensive care units and surgery; patients with tolstokishechny fistulas without the expressed symptomatology can receive treatment in office of gastroenterology or is out-patient. Therapy of intestinal fistulas is always begun with conservative actions. Completion of deficiency of liquid, normalization of an ion-electrolytic state is carried out. If in the field of the svishchevy course there is a purulent wound, abscess, the expressed dermatitis – the infection center eradikation which is followed by dezintoksikatsionny therapy is carried out.
Local therapy includes use of bandages with hypertensive and fermental solutions, antiseptic ointments and pastes. Protection of skin from intestinal separated by any available methods is made. Physical shielding consists in creation of a barrier between skin and liquid contents of intestines by means of pastes, glue (BF1, BF2), polymeric films, etc. A biochemical method – whistling for obkladyvany mouths the napkins moistened in egg white, milk, lactic acid. For mechanical protection use the various aspirators and obturators interfering allocation of intestinal contents outside. Apply gistaminoblokator, proteolytic enzymes to neutralization of gastric and pancreatic juice.
During conservative treatment it is necessary to adjust full and various enteralny, and if necessary and parenteral food. Conservative actions can lead to closing of the created tubular fistulas within one-two months. Spongy fistulas demand expeditious treatment, however the listed directions of not surgical treatment are used in quality of training to operation. Operation is shown also at tubular fistulas if conservative actions did not lead to spontaneous closing of the svishchevy course. It can occur with impassability of an intestinal tube distalny whistling; if the foreign matter served as the reason of formation of fistula; at formation of very high fistulas with a large number of separated; at the accompanying inflammatory diseases of intestines; at detection of a cancer tumor in a disintegration stage.
Surgical treatment demands thorough, long preoperative training. An exception are high tonkokishechny fistulas with formation of polyorgan insufficiency – at their existence preparation should not take more than several hours. During operation definition of exact localization of fistula, its excision together with an affected area of a gut, imposing of an interintestinal anastomoz is made. At some types of fistulas their vnebryushinny closing is possible.
Forecast and prevention of intestinal fistula
Mortality after expeditious treatment of intestinal fistulas reaches 2-10% (depending on a type of fistula and a condition of the patient before operation). The most frequent causes of death of such patients – sepsis and a renal failure. At timely identification of the svishchevy course its spontaneous closing against the background of conservative therapy in 40% of cases is possible. Prevention of formation of intestinal fistulas consists in timely detection and treatment of the background diseases leading to formation of the svishchevy courses.