Intestinal fistulas

Intestinal fistulas are abnormal communications between the gut and an adjoining viscus or skin. They may be classified into those arising from diseased bowel (type I), where spontaneous closure is unlikely or injury to otherwise normal bowel (type II), where closure is more likely. They present a complex management problem, often involving a multidisciplinary team (surgeons, gastroenterologists, intensivists, dieticians, stoma therapists, pharmacists, experienced nursing staff, clinical psychologists). The management of type-I fistulas requires attention to the primary disease, and treatment is often surgical. Type-II fistulas, which arise postoperatively from damage to normal gut, should be managed initially by resuscitation because these patients can be severely septic. The next step, restitution, requires attention to 'SNAP' (sepsis, nutrition, anatomy and plan). Surgical reconstruction can then be planned, followed by rehabilitation.