Gastrointestinal fistulae can be one of the most challenging complications of intestinal disease to manage. These abnormal tracts connect the epithelialised gut surface to either another part of the gut, another organ or tissue, or to the skin (table 1). This connection can cause enteric contents to bypass important absorptive surfaces, resulting in insidious malnutrition or overt diarrhoea, infection within other organs or the exquisitely embarrassing occurrence of having faeculant material in a woman’s vagina or on a person’s skin. Understandably, this can have a major impact on a person’s quality of life and psychological wellbeing and hamper overall prognosis in terms of general health and wellbeing. Through careful multidisciplinary management of the situation much can be done to address the fears and expectations of patients: careful stoma management, medical therapies to control output, nutritional support and consideration of the central role that surgery plays in resolving a fistula.
Enterocutaneous and enteroatmospheric fistulae both connect the gut to the skin, but the difference between them is whether there is skin around the fistula opening (enterocutaneous) or the fistula opens onto a laparostomy wound (enteroatmospheric). Most enterocutaneous fistulae develop following surgical intervention; however, fistulae can occur spontaneously. Spontaneous fistulae typically arise with mucosal inflammation such as that occurring with Crohn’s disease, but they can also appear in patients with neoplasia, following radiation treatment, or in the presence of foreign bodies or infections (e.g. tuberculosis or actinomycosis).
Here, we focus on the errors that can be made when managing enterocutaneous fistulae, based on our clinical experience and the available evidence.