Fistula Types, Diagnosis, Treatment, and Prognosis

A fistula is defined as an abnormal connection of two body cavities (such as the rectum and the vagina), or as the connection of a body cavity to the skin (such as the rectum to the skin). One way a fistula may form is from an abscess—a pocket of pus in the body. The abscess may be constantly filling with body fluids such as stool or urine, which prevents healing. Eventually it breaks through to the skin, another body cavity, or an organ, creating a fistula.

Fistulas are more common in Crohn's disease than they are in ulcerative colitis. Approximately 25 percent of people with Crohn's disease develop fistulas. Fistulas are typically treated with surgery or with wound care.

Fistulas often occur in the area around the genitals and anus (known as the perineum). The four types of fistulas are:

• Enterocutaneous: This type of fistula is from the intestine to the skin. An enterocutaneous fistula may be a complication of surgery. It can be described as a passageway that progresses from the intestine to the surgery site and then to the skin.
• Enteroenteric or Enterocolic: This is a fistula that involves the large or small intestine.
• Enterovaginal: This is a fistula that goes to the vagina.
• Enterovesicular: This type of fistula goes to the bladder. These fistulas may result in frequent urinary tract infections, or the passage of gas from the urethra during urination.

Symptoms of fistulas can include pain, fever, tenderness, itching, and generally feeling poorly. The fistula may also drain pus or a foul-smelling discharge. These symptoms vary based on the severity and location of the fistula.

Fistulas are usually diagnosed through the use of a physical exam, a computed tomography (CT) scan, and, if needed, other tests such as a barium enema, colonoscopy, sigmoidoscopy, upper endoscopy, or fistulogram.

During a fistulogram, dye is injected into the fistula, and X-rays are taken. The dye helps the fistula to show up better on the X-rays. The dye is inserted into the rectum, similar to an enema, for fistulas that are in the rectum. The dye must be 'held' inside during the procedure. With a fistula that is to the outside of the body, the dye is put into the opening with a small tube. X-rays will be taken from several different angles, so a patient may have to change positions on the X-ray table. As with any other kind of X-ray, remaining still is important.

When it's suspected that a patient has an enterovesicular (bladder) fistula, an intravenous pyelogram (IVP), another type of X-ray, may be performed. Prepping for this test may include a clear liquid diet or fasting, because stool in the colon can obstruct the view of the bladder. The dye (contrast material) is injected into the arm, and several X-rays are taken.

A fistula may cause complications. In some cases, fistulas might not heal, and become chronic. Other potential complications include fistula drainage, sepsis, and perforation and peritonitis. Sepsis is a life-threatening illness that results from the body's response to a bacterial infection. Symptoms of sepsis include a rash, fever, chills, confusion, disorientation, and rapid breathing and heart rate. Peritonitis is an inflammation or infection of the peritoneum, the tissue on the abdominal's inner wall that covers the abdominal organs. Symptoms of peritonitis include abdominal pain and tenderness, fever, chills, joint pains, nausea, and vomiting.

Treatments for fistulas vary depending on their location and severity of symptoms. Medical treatments include Flagyl (an antibiotic), 6-MP (an immunosuppresant), or certain biologic therapies (including Remicade and Humira).

An enteral diet may be prescribed for enterovaginal, enterocutaneous, and enterovesicular fistulas. An enteral diet is liquid nutrition that is taken by mouth or given through a feeding tube. These liquid nutrition formulas replace solid food and contain vital nutrients. With no solid food there is less stool passing through the anus, which helps the fistula heal and maybe even close.

Many fistulas will not respond to any of the above therapies and will require surgery and/or wound care. If the fistula is in a healthy part of the intestine, it may be removed without taking out any part of the intestine. If the fistula is in a very diseased part of the bowel, a resection may have to be performed.

A resection may result in a temporary ileostomy. Stool is diverted through the ileostomy, giving the part of the intestine with the fistula time to heal. This type of surgery is most often done on rectovaginal or enterovesicular fistulas.

The location and severity of the fistula play a major role in determining treatment. A fistula is a sign of serious inflammatory bowel disease (IBD), and without proper care, can lead to serious complications. Seeing a gastroenterologist on a regular basis and taking medication as prescribed is vital to the management and prevention of IBD complications.