Care of Patients With Enterocutaneous Fistula
Enterocutaneous fistulae (ECF) are challenging for clinicians to manage medically. For patients, ECF are devastating. As a certified wound and ostomy nurse, the author has provided care for numerous patients with ECF. One patient who had a fistula for years applied a new pouch system daily to manage the drainage. Due to the high output, this process would take him 1 to 2 hours each day. His wife discussed his frustration in dealing with the fistula. He described his embarrassment as the pouch system leaked during presentations at work. When he was on vacation, he became desperate to stop the leakage and keep a pouch intact. He inserted a hard plastic tube into the fistula to divert the output (risking bowel perforation).
DEFINITION
An ECF is a connection between the gastrointestinal tract and skin. Development of an ECF is unexpected and often occurs in an undesirable location. Approximately 80% occur as a complication from abdominal surgery.1 The incidence of fistulae is 5.5% in patients undergoing abdominal surgery.2 Patients at high risk include those with a history of trauma, inflammatory bowel disease, and oncologic surgery.1 The acronym FRIEND–foreign body, radiation, inflammation or infection (diverticula, tuberculosis, actinomycosis), epithelialization of the fistula tract, neoplasm, and distal obstruction–can be used to identify the risk factors that contribute to fistula development.1 Twenty percent (20%) of ECF occur spontaneously due to systemic diseases such as Crohn disease (regional enteritis), malignancy, radiation enteritis, and intra-abdominal sepsis.1
MANAGEMENT
Enterocutaneous fistula management requires a multidisciplinary team to address the following: sepsis, definition of the fistula, output, nutrition, skin and wound care, psychological support, and possible surgical management.3 Patients with ECF should be treated initially with the least aggressive and safest approach, that is, nonoperatively.4 Management of these cases may require a colorectal surgeon, dietitian, wound ostomy continence nurse, general surgeon, and gastroenterologist. Early recognition and treatment of sepsis decrease the mortality rate due to ECF.1 In addition, initial fluid resuscitation, electrolyte repletion, and supplemental enteral and parenteral nutrition lead to successful treatment of ECF.5
Evaluation of an ECF is necessary for understanding the location of the fistula, length of bowel remaining, and nutrition needs of the patient.4 Computed tomography usually is the initial test completed that is helpful to delineate the fistula. Magnetic resonance imaging may be helpful when a fistula is suspected but not identified on the computed tomography scan.
Oral fluids may be restricted to support the closure of the fistula. Additionally, gastric antisecretory medications (anticholinergics, proton pump inhibitors, and histamine-2 receptor antagonists), antidiarrheal medications (loperamide, diphenoxylate/atropine, and codeine), and somatostatin and its synthetic analogues (octreotide and lanreotide) may be required to decrease amount of effluent. However, there is minimal evidence that these medications support spontaneous closure.5
Long-term parenteral nutrition or enteral feeding should be considered to prevent malnutrition and optimize patients’ nutritional status. Oral intake or enteral nutrition may be feasible in patients with low output from the ECF; however, high output may require parenteral nutrition to support spontaneous or surgical closure.6 Fistulocysis can deliver enteral nutrition into a distal opening for those who have an intact gastrointestinal tract. These feedings can be fluid, elemental formula, or chime (effluent refed distally from a proximal fistula).3
Output from an ECF is highly corrosive to the skin; therefore, it is essential to develop an effective management plan that minimizes pain, prevents trauma, and facilitates patient mobility. Ideally, a leak-proof system should last 24 hours.7 Options for drainage management are dressings, including negative pressure wound therapy, and wound pouch systems. However, containment of the output becomes challenging to manage when output is high. The medical team often must think outside the box to contain the output.
Patients with an ECF use their supplies more quickly because these fistulae are extremely challenging to pouch. Whereas an ostomy usually is in a planned location, a fistula is not. This results in most fistulae being in locations that are difficult to pouch. The creases and contours around the fistula create complexity. Additionally, a fistula may be in a wound site, further causing pouching complications. Accessory products (paste, barrier rings, and strip paste) are helpful for containing the drainage.
THE PATIENT PERSPECTIVE
Living with an ECF dramatically decreases patients’ quality of life.8 Leakage of effluent contributes to odor and denuded skin conditions that cause severe pain (Figure). It also can lead patients to become dependent on others. Patients experience loss of normalcy, fear of leakage, and often are unable to work. Issues with the fistula prevent participation in social activities. About 50% of people living with a fistula change their management system more than once daily, with the average being 3 to 4 times per day.8
Approximately 90% of fistulae will close on their own within 5 weeks of medical management.1 When surgical intervention is required, it should be delayed for at least 6 months after the original surgery to allow adhesions to soften, which lowers the risk of mortality, morbidity, and fistula recurrence.3 There is a 19% recurrence rate of fistulae after surgery, which leads to patients living long term with a fistula.9 Additionally, some people with spontaneous fistulae live the remainder of their lives with an ECF.
Further exacerbating the problem, in the United States, Medicare coverage for patients with ECF is limited.10 Medicare pays for ostomy supplies only when an ostomy is “surgically created.” Ostomy supplies for managing a fistula are not covered by Medicare. Medicare will only cover wound supplies, including wound managers, for patients with surgically created fistulas, not for those who develop fistulas due to nonsurgical reasons such as inflammatory bowel disease.10
Because fistulae vary in size, location, output, and complexity, multiple pouching options may improve patient outcomes. Ostomy supplies and accessories may lead to an improved quality of life because they are designed for drainage of fecal effluent. Ostomy supplies are necessary to achieve prosthetic function to maintain health and wellness physically and emotionally. They allow people to be independent in society and lead full, productive lives. Currently, those who live with spontaneous ECF cannot obtain coverage for any supplies because most commercial insurers follow the coverage guidelines of Medicare. This coverage gap leads to a financial burden for patients and increases health care costs because these patients often remain hospitalized until surgical closure is achieved.
CONCLUSION
Enterocutaneous fistula treatment is a challenge that requires multiple providers to meet the health care needs of the patient. Complex pouch systems often need to be devised to protect the skin and manage drainage. Sadly, it is even more difficult to obtain any insurance coverage for the required supplies. Currently, UOAA is involved in advocacy efforts with the WOCN Society to change the Medicare policy for coverage of ostomy supplies to manage fistulae. See the UOAA position statement for more information.
REFERENCES
1. Cowan KB, Cassaro S. Enterocutaneous fistula. In: StatPearls. StatPearls Publishing; 2021.
2. Wercka J, Cagol PP, Melo AL, Locks Gde F, Franzon O, Kruel NF. Epidemiology and outcome of patients with postoperative abdominal fistula. Rev Col Bras Cir. 2016;43(2):117–123. doi:10.1590/0100-69912016002008
3. Adaba F, Vaizey CJ, Warusavitarne J. Management of intestinal failure: the high-output enterostomy and enterocutaneous fistula. Clin Colon Rectal Surg. 2017;30(3):215–222. doi:10.1055/s-0037-1598163
4. Tuma F, Crespi Z, Wolff CJ, Daniel DT, Nassar AK. Enterocutaneous fistula: a simplified clinical approach. Cureus. 2020;12(4):e7789. doi:10.7759/cureus.7789
5. Gribovskaja-Rupp I, Melton GB. Enterocutaneous fistula: proven strategies and updates. Clin Colon Rectal Surg. 2016;29(2):130–137. doi:10.1055/s-0036-1580732
6. Kumpf VJ, de Aguilar-Nascimento JE, Diaz-Pizarro Graf JI, et al. ASPEN-FELANPE clinical guidelines. JPEN J Parenter Enteral Nutr. 2017;41(1):104–112. doi:10.1177/0148607116680792
7. Metcalf C. Considerations for the management of enterocutaneous fistula. Br J Nurs. 2019;28(5):S24–S31. doi:10.12968/bjon.2019.28.5.S24
8. Hoeflok J, Jaramillo M, Li T, Baxter N. Health-related quality of life in community-dwelling persons living with enterocutaneous fistulas. J Wound Ostomy Continence Nurs. 2015;42(6):607–613. doi:10.1097/WON.0000000000000167
9. de Vries FEE, Atema JJ, van Ruler O, Vaizey CJ, Serlie MJ, Boermeester MA. A systematic review and meta-analysis of timing and outcome of intestinal failure surgery in patients with enteric fistula. World J Surg. 2018;42(3):695–706. doi:10.1007/s00268-017-4224-z
10. Center for Medicare & Medicaid Services. Surgical dressings – policy article: A54563. January 3, 2020. Updated March 12, 2021. https://www.cms.gov/medicare-coverage-database/view/article.aspx?articleId=54563. Accessed November 10, 2021
Ms Erbe has more than 30 years of experience in inpatient and clinic care settings. She is committed to improving outcomes and quality of care for patients with wounds and ostomies and serves on United Ostomy Associations of America, Inc. (UOAA) Education Committee. Please send inquiries to advocacy@ostomy.org. Information in this article was provided by UOAA. UOAA does not endorse particular products, manufacturers, providers, or other sellers of ostomy products. This column was not subject to the Wound Management & Prevention peer-review process.
