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Ms. Pickles & the ENTEROCUTANEOUS

FISTULA

Anna C. GramlApril 26, 2010NUTN 515

Meet, Ms. Pickles

A 42 year old, morbidly obese woman, sent from a SNF s/p Small Bowel Obstruction (SBO) & Resection Anastomosis 8 mo ago which was complicated by an Anastomotic Leak, Pelvic Abscess & an Enterocutaneous Fistula (ECF)

A Preview

A Familiar Face

Operations & Complications

Management and Treatment Options

Nutritional Approaches (as suggested by the literature)

Nutritional Assessment

Story Time

In A Nut Shell

References

Purple= Associated withMs. Pickles case

A familiar face to the OHSU squadDate Reason for Admit/Procedure Complications/ Action Taken

2000 Large B Cell Lymphoma s/p RCHOP, Cholecystectomy

2005 Ventral Hernia Repair c/b dehiscence

Sept 2, 2009

SB Obstruction from phytobezor—impacted pickles

SB Resection

High-output on POD2. C/b anastomotic leak, fungemia, bacteremia. Candida Parasilosis fungemia. Fluid collections in abdominal cavity. Intra-abdominal abscess. Sept 7 Repair: small bowel anastomosis

Sept 19 Ex -Lap TPN. Post-op Ex-Lap c/b ECF

Oct 18 Ex-Lap pelvic abscess Anastomatic leak & Pelvic abscess

Jan 2010

Intense fevers, chills, sweats, fatigue, malaise, dirty blood/urine

Bacteria d/t infected PICC line, line sepsis, ECF, skin infection, malnutrition. Open abd wound surrounding piece of bowel w/ multiple fistulas

Feb 2010

N/V/tachycardia, fever Fistula bleeding (1st time); visible. Peristalsis vegmatter found in large ECF. Hct 25.7.

March 2010

Fever 102F, Delirium, UTI, Abd pain, N/V. Sepsis

Groshong infections, persistent rising of bacterima & fungemia

Small Bowel Obstruction & Resection

Obstruction- blockage of the bowel

Mechanical Something got in the way

Resection- removal of small bowel/intestine

Anastomosis

Normal Bowel AnastomosisObstruction

Phytobezoar

Anastomotic Leak

Ruptured intestinal anastomosis

5-7 days post-op

Anemia, malnutrition, & vit deficiencies Sepsis, UTI, wound infection, excessive wound

drainage, tachycardia, respiratory infections

Ms. Pickles started on TPN for the 1st time

Results with sepsis, intra-abdominal infection, abscess, fistula, wound dehiscence, reoperation

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Intra-abdominal Infection & Abscess

Collection of pus in peritoneal cavity Bacteria

Abdomen must remain open

Risk: sepsis, severe volume depletion, catabolism, tachycardia, respiratory alkalosis Peritoneal

cavity w/

fluid

Abdominal midsection

Ms. Pickles’ Operations & Complications

Phytobezoar

SB

Resection

Small Bowel Obstruction

c/b

Anastomotic

Leak

Sepsis &

Intra-abd

infection

Sepsis &

Intra-abd

infection

Ex-LapIntra-abdominal

abscess formation

Drainage

of abscess

Enterocutaneous

Fistula (ECF)

Anastomosis

Ex-Lap: Exploratory Laparotomy

Exploration of abdominal cavity

What are the risks?

Development of fistulas within loop of bowel

Secondary fistulas

Infection

Bleeding into abdominal cavity

Loss & retraction of tissues in abdominal wall

ECF: Enterocutaneous Fistula

Abnormal communication between bowel & skin Intestinal contents leak through to skin

Found within loops of bowel

Incidence: 75% to 85% (post-op)

15-25% (spontaneous)

Mortality: 10% to 30%Key factor in reducing mortality

ADEQUATE NUTRITION!!

ECF in an open abdominal wound

Open abd wound w/ exposed loops of bowel

Opening in small bowel allows contents to drain out of fistula onto exposed bowel surface & wound tissue

Bowel Fistula up close

MNT: Nutrition Diagnosis

Altered GI function, related to multiple ECFs, as evidenced by high fistula output & indication to initiate Parenteral Nutrition Support

Malnutrition, related to persistent sepsisand loss of protein through GI secretions, asevidenced by high fistula output 1700 ml, Albumin 2.6, Prealbumin15, Hbg 11.5, Na 133, Mg 1.6, & Phos 5.2

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ECF: Treatment Options

Spontaneous closure is the optimal outcome

Conservative (3 months)

Control of electrolytes, nutrition, antibiotic therapy

Surgical- When spontaneous closure fails

Drainage - 57% to 88% success

Needed to correct malnutrition

Management & Treatment Approaches

SOWATS Treatment GuidelinesSepsis Fever, failure respond to nutrition, jaundice, ↓ PAB, + fluid balance, edema

Optimize Nutrition

Status

Intervene after rehydration & correction of electrolyte imbalances

Within 24-48 hours of small bowel fistula ; high output Parenteral + trace elements & vitamins

EN not expected to close spontaneously

Wound Care Prevent maceration & excoriation of the skin by intestinal leakage from fistula

Anatomy Determine fistula information pertinent to surgeon, length of proximal bowel, and quality of the remaining bowel (obstruction/stenosis)

Timing Surgery

Septic foci treated and pt is in good clinical & nutritional condition.↑Albumin & Thrombocyte counts; CRP & Erythrocyte consistently WNL.

Surgical Strategy

Complete dissection of bowel tract to ensure unhindered passage & mobilization of abdominal wall. This facilitates closure at end of operation. Enterostomies may be constructed to protect more anastomoses that are at risk for leakage.

Nutrition is important, as always

Adequate nutrition reduces mortality rate

1500-2000 kcal/d = 16% mortality

< 1000 kcal/d = 58% mortality

1.5-2.5 gm pro/kg

Treating sepsis & restoring nutritional status = #1

Aggressive volume restoration & correction lytes

Replace high-output (lose vital nutrients & lytes)

Hyponatremia & Hypokalemia

Nutrition Intervention Options

NPO- high output

NPO + NGT (↓ GI secretions)

(unless otherwise indicated)

PO

CL, FL, Puree, Mechsoft, Regular

Artificial Nutrition

Enteral Nutrition (Elemental)

TPN

(ADA Evidence Analysis Library)

ENTERAL vs. TPN

Low OutputNearly impossible to provide

adequate nutrients

Preserves GI mucosal barrier; gut fxn

Immunologic

↑ fistula OP

Feeding intolerance

Inability access GI

High Output

Corrects malnutrition

↓ mortality rate

↑ rate spontaneous closure

Reverses catabolic state

GI secretions ↓ 30-50%

Catheter complications

Refeeding Syndrome

*Note: Artificial Nutrition is required while fistula heals

Ms. Pickles’ Nutritional Assessment

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Anthropometrics

5’8” (2.16 m2)131.5 kg (#290)BMI: 60.8

Weight historyNov 2008: 159 kgSept 2009: 167 kgJan 2010: 132-160 kgFeb 2010: 150 kgMar 2010: 131.5 kg

Ideal Body Wt63.6 kg (#140)207% IBW

Usual Body Wt (on 3/17 per pt)131.5 kg (#290)

Dosing Wt (TPN)67 kg (#147)

Biochemical DataElectrolytes

Na 133 mmol/L(Ref134-143)

Mg 1.6 mg/dL (Ref 1.7-2.5)

Phos 5.2 (Ref 3.5-4.7)

Endocrine Profile

Glucose 109 (Ref 80-99)

Respiratory values

Total CO2 20 mmol/L(Ref 23-31)

Anemia Profile

Hgb 11.5 g/dL (Ref 12-16)

Hct 33.8% (Ref 36-46)

PAB: 16 mg/dL (Ref 17-30)

*Note: Alb 2.6 g/L (Ref 4.0-4.7)

Liver Function Profile

BUN 28 mg/dL (Ref 6-20)

ALK Phos 661 U/L (Ref 42-98 U/L)

AST 59 U/L (Ref 15-41 U/L)

ALT 111 U/L (Ref 13-48 U/L)

Rx Tylenol 500 mg, tablet

Advair (inhaler)

Albuterol (Proventil) (inhaler )

Ambien 5 mg, oral

Ascorbic Acid, tablet 250 mg oral

Aspirin, Oral

Benadryl

Calcium Carbonate 500 mg, oral

Cipro 500 mg, tablet

Cholecalciferol 1,000 u, oral

Cyclobenzaprine

Cymbalta

D5/LR IV

Ferrous Sulfate 325 mg, tablet

Lovenex

Lorazepam (Ativan)

Lyrica

Methadone 10 mg, tablet

Morphine 1-4 mg, injection

Mylicon

Nitrostat

Oxycodone 5-10 mg, tablet

Phenergan 25 mg, tablet

Pregabalin (after 3/23 procedure)

Prevacid 30 mg, tablet

Reglan 10 mg, injection

Silvadene, Topical Cream (after 3/23 procedure)

Sucralfate

Trazodone 100 mg, oral

TUMS

Vancomycin 1.5 gm, IV

ZofranNote: only medications given during March hospital admission*

Pertinent MedicationsIndications Medication Interactions

Healing & ↑ Fe absorption Ascorbic Acid N/V/D gastric cramps

↓Gastric Acid secretion, N/V/D, abdominal pain

TUMSCan ↓ Fe & B12Ensure adequate Vitamin D

High fistula output & losses Cholecalciferol ↑ Ca absorption; dry mouth, N/V/D/C

Indicated with TUMSFerrous Sulfate

↑ anemia labs, N/V/D/C, dyspepsia, bloating

AntiBx: Hx infections Cipro, Vancomycin N/V/D, abd pain, ↑ LFTs, ↑ TG

Pain Narcotics +C, no grapefruit, ↑ BG

Antiemetic, ↓ GI irritation Phenergan ↑ BG, drowsiness, sedation

Promote fistula closure, Anti-diarrheal

OctreotideN/V/D/C/F, steatorrhea, abd pain, monitor lytes, ↓B12

Antiemetic, Anti-GERD, ↑ GI contractions & food motility

Prevacid, Reglan

↑Gastrin, LFTs, Chol, BG; ↓ B12

Anti-nausea Zofran Can ↑ LFT

Rx to take after D/C Pregalbin

Topical Cream

Tylenol (oral)

Ambien

Ondanstron

Promethazine

Scopolamin

Sucrafate

Trazodone

SF Boost TID Ascorbic AcidOxycodone

Bed ridden

Endentulous

Personal History

Female, 42 y/o

White, non-Hispanic

Social History• Lives @ SNF

• Single

• No children

• Non smoker (quit ’07)

• Non alcohol user

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1. Trichorhinophlangel Syndrome- TRPS 2. Pyelonephritis3. Asthma4. GERD5. Morbid Obesity (BMI > 60)6. Diverticulitis 7. Polysubstance abuse8. Large B Cell Lymphoma s/p RCHOP (2000)9. Cholecystectomy (2000)10. Ventral Hernia Repair- VHR (2005)11. Small Bowel Obstruction12. Small Bowel Resection & Anastomosis13. Ex Lap14. Enterocutaneous Fistula15. UTI16. Bacteremia & Fungemia 17. Dental Caries18. Malnutrition

Past Medical History Food/Nutrition Related History

NPO, CL, FL, Puree, Mech Soft, Reg, PPN, TPN

“Subjective Global Assessment” obtained 3/17/10

Decreased appetite

FL diet past 2 weeks at SNF

+N/V/D for past 2 weeks

Last BM: “months ago”

Bed ridden (doesn’t walk SNF)

Edentulous (4 teeth)

Muscle wasting

Nutrition education - Amy Dorman, RD High protein foods allowed with a Pureed diet

Score: CSeverely

Malnourished

Day 1: Admit & Physical Exam

Fevers (102*), hypotension, delirium, RLQ pain, +N/V few days, ↑ ECF size, diaphoretic

-BP: 113/54 mmHG -Respiratory: 30

-Temp: 37°C (98.6°F)* -Sp02: 98% Open abd wound w/ visible viscera, yellow d/c, wound has

mild erythema. Abd tender. No signs of anasarca or peripheral edema.

Tachycardic

MD: Septic & UTI FULL CODE

Day 1: Nutrition Consult (Anna)

TPN Recs: (dosing wt: 67 kg)

18 kcal/kg, 1.6 gm pro/kg, 20% lipids in 1560 ml vol

Cyclic: 16 hrs

45 ml/hr x 1 hr; ↑ to 105 ml/hr x 14 hrs; ↓to 45 ml/hr x 1 hr; off 8 hr

Added: Thiamine (100 mg), Folic Acid (1 mg), Vit C (500 mg), Zinc (5 mg), Selenium (200 mcg)

Diet Rx : Regular Fistula output- “high”

Na 136

↓ K 3.2

↓ Mg 1.6

↑ P 5.2

↑ BUN 21

↓ Ca 8.5

↓ Alb 2.6

↑ LFTs

Glu 95

Estimated Energy Needs

18 kcal/dosing wt kg =1206-1541 kcal/day1.6 gm/IBW kg = 65.4 gm protein/day

22-25 kcal/IBW kg = 900-1020 kcal/day2.5 gm/IBW kg = 102 gm protein/day

Inaccurate ht for first 2 days

Day 2

Day 2: Rounds with Dr. Martindale

Diet recall obtained TPN continues (18 kcal; 1.6 gm)

Removed ALL Phos↑ KCl to 50 mEq/L ↑ MOS4 to 14 mEq/L

Est. Needs to: 900-1020 kcal; 102 gm pro (IBW)

Diet Rx: Pureed Dr. Martindale recommended Mech Soft + Boost TID

Fistula output: 1700 ml/d UTI mgmt- AntiBx Therapy: Cipro

↓ K 3.2

↑ Mg 1.7

↑ P 5.2

↓ Ca 8.3

↓ Hct 26.7

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The Infamous Strawberries

Story Time Day 3: TPN Stopped; New recs (Anna)

• Oral feeding trial

• Ck Mg in 2 days

New dosing wt: 40.9 kg (IBW)

22 kcal/IBW kg = 900 calories

2.5 gm pro/IBW kg = 103 g pro

↑ CRP 2.8

↓Ca 8.3

↓PAB 14

Mg: n/a

Day 3: Mg 1.7 (previous lab)

NaCl 70 mEq/L

KCl 50 mEq/L

Kphos 0 mmol/L

MgSO4 14 mEq/LRe-ck 2 days

CaGluconate

5 mEq/L

MVI & TE Standard Amt

Zinc 5 mg

Thiamine 100 mg

Vitamin C 500 mg

Selenium 200 mcg**

Folic Acid 1 mg

Day 1: Na 136, K 3.2, Mg 1.6, P 5.2

NaCl 70 mEq/L

KCl 20 mEq/L

Kphos 15 mmol/L

MgSO4 8 mEq/L

CaGluconate

5 mEq/L

MVI 1 mL

Zinc 5 mg

Copper I mg

Manganese 0.5 mg

Chronium 10 mcg

Selenium 60 mcg

Day 2:

K 3.2, Mg 1.7, P 5.2, Ca 8.3

NaCl 70 mEq/L

KCl ↑ to 50 mEq/L**

Kphos ↓ to 0 mmol/L*

MgSO4 ↑ to 14 mEq/L**

CaGluconate

5 mEq/L

MVI & TE Standard Amt

Zinc 5 mg

Thiamine 100 mg

Vitamin C 500 mg**

Selenium 200 mcg**

Folic Acid 1 mg**

Day 3: No Mg

NaCl 70 mEq/L

KCl 50 mEq/L

Kphos 0 mmol/L

MgSO4 14 mEq/LRe-ck 2 days

CaGluconate

5 mEq/L

MVI & TE Standard Amt

Zinc 5 mg

Thiamine 100 mg

Vitamin C 500 mg

Selenium 200 mcg**

Folic Acid 1 mg

TPN: Electrolytes & Additives Day 4 & 6: No TPN

Day 4: Oral Intake Test

•Severe abd pain; +N•Diet Rx: Mech Soft + Boost TIDoStart Calorie count, per RD

•Fistula Output: 3150 ml

Day 6: BM x 1 (liquid)

↓ Mg 1.6

↑ Ca 8.7

↓ PAB 16

↓ Alb 2.6

↑ Hct 26.7

↑ Alb 2.7

↓ BUN 4

↑ PAB 17-tgt

↑ Hct 29.9

↑ LFTs

Calorie Count

Day 4 1473 calories 57 gm pro

Day 6 2318 calories 103 gm pro

Remember, Ms. Pickles’ estimated needs were…

900-1020 calories; 102 gm pro

Day 7: Nutrition Consult

AEB TPN d/c 3 days ago & calorie count started Tolerating & meeting needs on mechanical soft

Failed oral intake test “miserably” Copious fistula output with PO intake

May need restart TPN; PICC insertion scheduled

Fistula output: 925 ml/d

BM x 1 (liquid)

Recommended

MVI & Zinc Monitor PO, continue Mech Soft + Boost TID

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Continue TPN Rx @ SNF & allow for recreational PO with no fluid restriction

Corrected Na, K, Ca, Mg, Phos

Appropriate PAB (17)

Low albumin (2.7), High BUN (4) & LFTs

F/U as an outpatient in few weeks

Ready for fistula take down in 3 weeks

Day 8: Groshong Inserted & Ms. Pickles Discharged

In a Nut Shell

Cyclic TPN maintained without complications Obtained optimal electrolyte levels

Diet Rx changed

Met her needs, PO However, failed oral intake trial

New PICC placed, current TPN regimen to resume @ SNF

Recreational PO & no fluid restriction

A BIG THANKS

Dr. Robert Martindale

Marliese White, MS, RD, CNSD, LD

References

1) ADA Nutrition Care Manual

2) Schecter WP, Hirshberg A, Chang DS, Harris HW, Napolitano LM, Wexner SD, Dudrick SJ. Enteric fistulas: Principles of management. J Am Coll Surg. 2009; 209(4):484-490.

3) Thompson MJ, Epanomeritakis E. An accountable fistula management treatment plan. Br J Nurs. 2008; 17(7): 434-440.

4) Visschers RGJ, Olde Damink SWM, Winkens B, Soeters, van Gemert WG. Treatment strategies in 135 consecutive patients with enterocutaneous fistulas. World J Surg. 2008; 32:445-453

5) Cawich SH, McFarlane ME, Mitchell DIG. Fistuloclysis: A novel approach to the management of enterocutaneous fistulae. The Internet J Surg. 2007; 9(2): 1-5.

6) Kwon SH, Oh JH, Kim HJ, Park SJ, Park HO. Interventional management of gastrointestinal fistulas. Korean J Radiol. 2008; 9(6): 541-549.

References

7) Fekaj E, Salihu L, Morina A. Treatment of enterocutaneous fistula with total parenteral feeding in combination with octreotide: a case report. Cases Journal. 2009; 2(177).

8) Baars JE, Kuipers EJ, van Dekken H, van der Woude CJ. Surgery is indicated for persistent enterocutaneous fistulizing Chron’s disease. Clin Med: Gastroenterology. 2008;1:1-3 (Case Report)

9) Connolly PT, Antje Teubner ChB, Lees NP, Anderson ID, Scott NA, Carlson GL. Outcome of reconstructive surgery for intestinal fistula in the open abdomen. Ann Surg. 2008;247: 440-444.

10) Makhdoom ZA, Komar MJ, Still CD. Nutrition and Enterocutaneous Fistulas. J Clin Gastroenterol. 2000;31(3):195-204.

11) Dudrick SJ, Maharaj AR, McKelvey AA. Artificial nutritional support in patients with gastrointestinal fistulas. World J. Surg. 1999;23:570-576

12) ADA Analysis Library13) OHSU Suggested Guidelines for Nutritional Care14) Pronsky ZA. (2008) Food medication interactions. 15th edition. Burch Runville,

Maryland.