Fistula Repair for Crohn’s Patients

A fistula develops when there is a connection between two organs in the body, or an organ and the skin, that doesn’t belong there. Fistulas can result from different diseases and conditions, but they tend to be commonly associated with Crohn’s disease.

With Crohn’s disease (an inflammatory bowel disease causing inflammation of the digestive system), a fistula often affects the colon and the area around the anus (the perianal area). Having a fistula can be painful, embarrassing, and scary, and it can lead to a lower quality of life. Although it may take time for a fistula to heal, there are treatments available.

There are nonsurgical ways to heal a fistula, but fistula repair may require surgery. Some types of fistula repair are the rectal flap procedure, endoscopic fistula repair, a fistula plug, ligation of intersphicteric fistula tract (LIFT), and seton placement. This article discusses both surgical and nonsurgical ways to heal a fistula.

What Is a Fistula?

A channel that forms abnormally between two organs or an organ and the skin is called a fistula. Fistulas can happen anywhere in the body, but they most commonly affect the digestive system, or digestive tract. 

Having a condition such as inflammatory bowel disease (IBD), which includes Crohn’s disease and ulcerative colitis, increases the risk of developing a fistula. After the first year of diagnosis, people with Crohn’s disease have about a 21% chance of developing a fistula. About 12% of people with Crohn’s disease have a fistula at any given time.

Fistulas can be a special problem for women with Crohn's disease when they affect the vagina.

Inflammation and Fistula Development

Crohn’s disease can cause inflammation in any part of the digestive tract. Further, all the layers of the walls of the intestines can be affected. It’s thought that this inflammatory process may lead to the formation of fistulas.

The cells in the walls of the digestive tract are affected by the inflammation and will change. An abscess, which is a pocket of pus, may form. That abscess can grow and the result can be an abnormal connection, a fistula, between two organs.

Types of Fistulas in Crohn’s

There are several types of fistulas that are more common in people with Crohn’s disease. They can be classified in a few different ways.

One of the ways a fistula is classified is according to the location in the body. This includes:

• Perianal (in or around the anus)
• Rectovaginal (between the rectum and the vagina)
• Enterocutaneous (between the digestive tract and the skin)
• Internal (between two organs)
  

Another way fistulas can be classified is as either simple or complex. Most fistulas associated with Crohn’s disease are classified as complex. Complex fistulas may be more challenging to treat and heal. 

A fistula may be classified as complex if it:

• Is close to the anus
• Has more than one tract
• Is connected to a stricture (a narrowing in the intestine)
• Is associated with an abscess
  

Symptoms and Location

A fistula may have different symptoms based on where it is located.

An anal fistula may have symptoms such as:

• Anal itching
• Anal pain
• Draining pus from the anal area
• Fever
• Chills
• Fatigue
• Swelling or redness around the anus
  

A fistula that involves the bladder and the intestines can have symptoms of:

• Passing air out of the urethra (tube through which urine passes out of the body)
• Urine that smells like feces
• Urinary tract infections (UTIs)
  

Rectovaginal fistulas involve the rectum and the vagina and might cause:

• Abnormal discharge from the vagina
• Pain during vaginal sex
• Pus from the vagina
• UTIs
  

Fistulas between the large and small intestine might cause:

• Dehydration
• Diarrhea
• Malnutrition
• Undigested food in the stool
  

Fistulas between the intestines and the skin could lead to fecal matter (stool) leaving the body through the opening. Some fistulas might not cause any specific symptoms or the symptoms might not be pronounced enough to be noticeable or seem like they’re from a fistula.

By one estimate, the ratio of fistulas in Crohn’s disease is:

• Perianal: 55%
• Enteroenteric (between two parts of the small intestine): 24%
• Rectovaginal: 9%
• Enterocutaneous: 6%
• Enterovescical (between the intestine and the bladder): 3%
• Enterointrabdominal (between the intestine and another part of the abdomen): 3% 

Fistula Repair: Your Options

There are different options for treating a fistula, both surgical and nonsurgical. The treatments that are used will be based on the location of the fistula and how complicated it is, as well as other factors.

Nonsurgical

Some types of fistulas may respond to treatments such as medications or special nutrition, and surgery won’t be needed.

Antibiotics: When stool is involved, there can be a risk of an infection from the bacteria it contains. Antibiotics may not be all that’s needed to heal a fistula but may help in preventing future complications.

Biologics: Biologic medications can help in reducing the inflammation caused by Crohn’s disease. This class of drugs may also help in healing a fistula.

If there are abscesses, those may need to be treated with antibiotics before a biologic can be used. This is because some biologic medications (especially those classified as antitumor necrosis factor inhibitors) may increase the risk of infections.

Immunosuppressants: Because a fistula may be associated with the inflammation from Crohn’s disease, treating that problem with these medications may be important. These drugs may work better in the case of uncomplicated fistulas.

Nutritional therapy: Nutritional therapy is sometimes used to treat Crohn’s disease, more often in children than in adults. If a fistula involves the bowel, giving that area a rest from solid stool moving through it may help it to heal. In that case, enteral nutrition or intravenous nutrition might be used.

Enteral nutrition is liquid nutrition, in which all or most calories are from specially fortified drinks delivered directly into the gastrointestinal tract. Intravenous nutrition, or parenteral nutrition, is delivering a special formula intravenously (IV, through a vein), and few or no calories are taken in through food. 

Surgery

Surgery is sometimes needed to treat a fistula. Surgery may be used along with medical therapy to heal a fistula. If there are abscesses, those are usually drained or treated with antibiotics prior to having surgery. Surgery includes:

• Advancement flap: This treatment may be used for a complex fistula involving the anus or rectum (perianal fistula). The tissue of the rectum is used to close the opening of the fistula. This procedure may help avoid any loss of muscle tone in the anal sphincter (the muscle that controls the release of stool) because that could lead to stool leaking.
  
• Endoscopic repair: When a fistula involves the portion of the upper digestive tract, it might be repaired with this procedure. An endoscope (a lighted, thin tube with a camera) is passed through the mouth, down through the esophagus and stomach, and into the small intestine. The tools on the endoscope are used to repair the fistula.
  
• Fibrin glue, collagen plug or paste: The fistula is closed using material made of a special kind of protein. The internal opening is closed surgically, and the protein is used on the external side.
  
• Fistula clip: A special type of clip is inserted surgically to close off the internal side of the fistula. This helps it to heal.
  
• Ligation of intersphicteric fistula tract (LIFT): A special tool is used to make an incision in the anal canal to cut into the fistula and widen it. After it heals, any infection is removed, and the internal side of the fistula is closed up.
  
• Setons: A seton is a type of thread or other material that is passed through the fistula to help with drainage. It may be left in place for several weeks or months until the fistula starts to heal. In some cases, the seton is tightened over a series of weeks to encourage the formation of scar tissue and help the fistula close. 

Seeing a Specialist

Fistula repair is complicated and requires care from a specialist. Unfortunately, some fistulas are difficult to heal and there is a possibility that they may return.

Fistula repair will be done by a colorectal surgeon. For people who have complex fistulas, it may be necessary to work with a colorectal surgeon that specializes in these procedures.

A gastroenterologist (a doctor specializing in treating disorders of the stomach and intestines) may also be part of the team when medical treatment is necessary. There may be other healthcare professionals involved as well, including a surgical nurse or gastrointestinal nurse. 

Ongoing Management and Aftercare 

There may be special care needed for the surgical area after a fistula repair. A sitz bath (sitting in a shallow pan of water) may be recommended in some cases. Stool softeners could also be part of recovery to prevent hard bowel movements. Wound care instructions will be given by a surgeon or a nurse.

Surgical treatments aren’t without risks. Some of the potential complications after surgical treatment of a fistula include: 

• Incontinence (loss of bowel control)
• Infection
• Recurrence of the fistula

Going to the Bathroom

It’s important to take special care of the perianal area after having fistula surgery. There could be discomfort or pain during bowel movements. Avoiding constipation and keeping the stool soft by drinking enough water, eating fiber, and using stool softeners may be recommended. 

Ice packs might be used in the area to prevent swelling and to help with discomfort. Wiping after a bowel movement may be uncomfortable so using a bidet (toilet attachment that sprays water), wet wipes, or a peri bottle (a squirt bottle designed to reach the perianal area) could help.

Feeling Secure 

Being diagnosed with a fistula is challenging. It can be embarrassing to discuss, especially when the fistula involves the anal area or the vagina. However, it’s also important to tell your doctor everything about the fistula, including if it’s causing pain or if there is stool coming from the opening on the skin or the vagina.

It may help to work with a mental health professional to work through the emotions involved. If you are in a relationship, you may wish to seek couples therapy, especially when a fistula is impacting intimacy.

Having fears regarding a fistula and its treatment is expected. It’s challenging to tell a healthcare team about these concerns, but healthcare providers may be able to put many of your worries in perspective and help you cope. An ostomy or wound care nurse will be a good resource in learning how to manage a fistula.

Summary

People with Crohn's disease may develop a fistula, an abnormal connection between two organs or an organ and the skin, in the digestive tract due to inflammation. A perianal fistula, a fistula between two parts of the intestines, and a fistula between the rectum and vagina are the three most common types.

There are surgical and nonsurgical options for treating fistulas. Which is right for you will depend on the location of the fistula and the complexity of treatment. After treatment, constipation must be avoided.

A Word From Verywell

Having a fistula is inconvenient, uncomfortable, and embarrassing. It is necessary to get it treated, however, in order to avoid more serious complications. In some cases, it may be necessary to advocate for yourself to get healthcare providers to look into the symptoms and to find the fistula.

There are some choices to make regarding treatment options. Understanding the potential effects may take time and asking a lot of questions. However, it will be worth the time and effort because healing the fistula is important in preventing a recurrence and improving your quality of life.