Small Bowel Fistulating Disease

Mr Paul Rooney RLUH

Powerpoint File

Surgical intervention is required for most patients with primary Crohn's fistulation. Patients with fistulating Crohn's disease are dominated by the problems of sepsis and nutrition. Often with a clinically palpable mass discharging through the abdominal wall, right iliac fossa, infra inguinal psoas abscess. There are a number of priorities. Firstly the examination of sepsis, via CT guided percutaneous drainage or open drainage, and the provision of nutritional support, preferably enteric, with good wound and stoma care ensuing.

This period of stabilisation is followed by resection of primary Crohn's disease causing the fistula. In doing so, one must also take into account the safety of performing intestinal anastomosis, with perhaps a safer option of primary stoma versus delayed intestinal anastomosis. All treatment options must be balanced against both fears the of the surgeon, and fears of the patient, including disfigurement, stoma, the possibility of short gut syndrome, together with death. Surgical treatment is therefore based on a number of delaying tactics. Draining the abscess and eradicating the sepsis, and allowing the patient to recover. Nutritionally however, this merely delays the prospect of surgery for the removal of Crohn's underneath. It may therefore be preferable to perform a laparotomy with simultaneous resection of the disease and drainage of the associated abscess.

Post-operative Crohn's fistula (typeII) secondary to anastomotic breakdown, breakdown of enteric repair or iatrogenic injury which is unrecognised require resuscitation, restitution, reconstruction and rehabilitation. Simple resuscitative measures in this situation are obvious, but stoma care and psychiatric support are just as important. The patient then requires a period of restitution whereby sepsis nutrition anatomy and a plan can be devised to achieve either a spontaneous or surgical closure of the fistula. Reconstruction may require a further anastomosis, and an abdominal closure perhaps six months after the initial insult. This is further followed by a period of rehabilitation and reintegration into society.

References.

Abdominal Fistulising Crohn's Disease. Ruben West, Nigel Scott. 589-603 in Inflammatory Bowel Diseases. Jack Satsangi… Lloyd Sutherland 2003