A slide on Fistula and its management.pptx

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1. FISTULA 1

2. OUTLINE INTRODUCTION EPIDEMIOLOGY ETIOLOGY PATHOPHYSIOLOGY CLASSIFICATION AND TYPES RISK FACTORS CLINICAL PRESENTATION DIAGNOSIS INVESTIGATIONS COMPLICATIONS GOALS OF THERAPY MANAGEMENT ROLE OF THE PHARMACIST CONCLUSION REFERENCES 2

3. INTRODUCTION A fistula is an abnormal connection between two or more epithelial surfaces, organs or vessels that do not normally connect. It can occur in various parts of the body, such as the gastrointestinal tract, urinary tract, neck and throat, reproductive organs, skin, rectum and anal regions. Fistulas can lead to significant discomfort, complications, and impaired organ function. 3

4. EPIDEMIOLOGY Globally, every year between 50,000 and 100,000 women are affected by fistula relating to childbirth. It is estimated that more than 2 million young women live with untreated obstetric fistula in Asia and sub-Saharan Africa. The incidence of a fistula-in-Ano developing from an anal abscess ranges from 26% to 38%. 4

5. ETIOLOGY 1. Inflammation and/or infection (abscess formation) 2. Trauma or injury 3. Surgical complications 4. Inflammatory bowel disease e.g. Crohn's disease 5. Side effects of treatments. E.g. radiation therapy 6. Other infections such as diverticulitis, tuberculosis, etc. 5

6. PATHOPHYSIOLOGY Fistulas typically result from tissue damage or inflammation, which leads to the formation of an abnormal tract between organs or vessels. The specific pathophysiology varies depending on the underlying cause and location of the fistula. (a) Infection & Inflammation: The process usually begins with a localized infection, often bacterial, that triggers an inflammatory response. The immune system sends WBCs (neutrophils, macrophages) to the site of infection to combat the invading pathogens. Inflammation increases vascular permeability, allowing more immune cells and proteins to enter the affected area. This leads to the accumulation of pus (a thick fluid composed of WBCs, tissue debris, and bacteria). (b) Tissue damage & necrosis: As the immune response intensifies, a central area of necrosis forms where tissue cells die due to the infection and ischemia. 6

7. PATHOPHYSIOLOGY (c) Abscess formation: The surrounding viable tissue walls off the necrotic area, creating a cavity filled with pus, known as an abscess. The abscess is surrounded by a fibrous capsule that forms as part of the body’s attempt to isolate the infection and prevent it from spreading. (d) Fistula tract development: As the abscess erodes through tissues, it creates a narrow, epithelialized tunnel or tract that connects the abscess cavity to another surface, such as skin, an organ or another body cavity. This tract, lined by granulation tissue and eventually epithelial cells, becomes a fistula. The fistula provides a continuous pathway for the drainage of pus or other fluids from the abscess, which can prevent the abscess from fully healing. 7

8. CLASSIFICATION OF FISTULA 1. Congenital Fistula : A type of fistula present at birth. E.g. Brachial fistula, Tracheo -esophageal fistula. 2. Acquired Fistula : They are abnormal connections that forms between two organs or vessels due to injury, infection or surgical processes after birth E.g. Entero-cutaneous fistula, entero-enteric fistula, entero-vaginal fistula, genitourinary fistulas. 8

9. TYPES OF FISTULA Based on the surfaces or organs involved; 1. Arteriovenous fistula: This describes an abnormal communication between an artery and a vein. 2. Enterocutaneous fistula : A n abnormal communication between the small or large bowel and the skin. It can arise from the duodenum, jejunum, ileum, colon or rectum. 3. Anal fistula or Fistula-in-Ano : A n abnormal tunnel-like connection that forms between the anal canal or rectum and the skin near the anus. 9

10. TYPES OF FISTULA 10

11. TYPES OF FISTULA 11

12. TYPES OF FISTULA 4. Enterovesical fistula : They are also known as vesicoenteric or intestinovesical fistula occurring between the bowel and the bladder. 5. Bronchopleural fistula : An abnormal passage way that develops between the large airways in the lungs(bronchi) and the space between the membranes that lines the lungs(pleural cavity) resulting from lung infections like tuberculosis. 6. Obstetric fistula : It is an abnormal opening formed between the birth canal (genital tract) and the urinary tract or rectum due to obstructed labor during childbirth. 12

13. TYPES OF FISTULA 7. Vaginal fistula : It is an abnormal opening that connects the vagina to another organ such as the bladder, colon or the rectum. The different types of vaginal fistulas include; (a) Vesicovaginal fistula : Also called bladder fistula. I t is a common type of vaginal fistula. The opening develops between the vagina and urinary bladder. (b) Urethrovaginal fistula: It is also called urethral fistula. This type of fistula develops between the vagina and the tube that carries urine out of the body (urethra). 13

14. TYPES OF FISTULA (c) Ureterovaginal fistula : This type of fistula develops between the vagina and the ducts that carry urine from the kidneys to the ureters (bladder). (d) Rectovaginal fistula : This type of fistula develops between the vagina and the lower portion of the large intestine (rectum). (e) Colovaginal fistula : This type of fistula develops between the vagina and the colon. (f) Enterovaginal fistula : This type of fistula develops between the vagina and the small intestine. 14

15. TYPES OF FISTULA 15

16. RISK FACTORS 1. Surgical procedures 2. Inflammatory bowel disease 3. Cancer and radiation therapy 4. Appendicitis 5. Perforation of duodenal ulcers 6. Abdominal trauma ( eg . gunshot wounds, stabbing, or motor vehicle accident) 7. Aortic aneurysm, infected aortic graft, or previous abdominal aortic surgery 16

17. CLINICAL PRESENTATION Symptoms vary among different kinds of fistula; Non-specific Symptoms: ( i ) Nausea (ii) Vomiting (iii) Diarrhea (iv) Abdominal pain (v) Fever with supposed infections (vi) Leakage of fluids or blood. 17

18. CLINICAL PRESENTATION Specific Features ; 1. Anorectal fistula (fistula-in-Ano): Pain on sitting down, recurrent anal abscesses, discharge of pus or blood from an opening near the anus, skin irritation at the anal area. 2. Enterocutaneous fistula: Leakage of fecal material or digestive fluids through the skin, skin irritation. 3. Arteriovenous fistula (AV fistula): May be asymptomatic, swelling of the limbs, fatigue, heart palpitations, and high blood pressure 18

19. CLINICAL PRESENTATION Specific Features ; 4. Vesicovaginal fistula : Leakage of urine into the vagina (incontinence), frequent infections, irritation or discomfort in the vaginal area. 5. Rectovaginal fistula: Passage of gas or feces through the vagina (fecal incontinence) and recurrent vaginal or urinary tract infections. 6. Entero-enteric fistula : Prolonged periods of diarrhea 19

20. DIAGNOSIS 1. Medical history and physical examination 2. Imaging studies (Ultrasound, CT scan, MRI, X-ray) 3. Endoscopic procedures ( Colonoscopy, cystoscopy) 4. Blood Test Or Urine Test (Inflammation, Infections) 5. Fistulography (Injection of a dye into the fistula for visualization) 6. Swab of the pus for microscopy, culture and sensitivity of isolated organisms. 20

21. INVESTIGATIONS To locate Fistula; X-ray- Shows any foreign body. Fistulography - Length & width of the fistula, anatomical location, the presence of any distal obstructions. CT Scan- Highly recommended for duodenal & pancreatic fistulae. USG - Locating intra-abdominal abscesses, guided aspiration. Endoscopy -Principal use is in internal fistulae. 21

22. COMPLICATIONS 1. Infection. 2. Nutritional deficiencies. 3. Fluid and electrolyte imbalance. 4. Fecal or Urine incontinence. 5. Impaired organ function. 6. Fistula expansion. 7. Psychological impact. 22

23. GOALS OF THERAPY 1. To achieve closure or healing of the fistula. 2. To prevent and treat infections. 3. To relieve patient of symptoms. 4. To preserve or restore function of the affected organ. 5. To prevent complications. 6. To prevent reoccurrence. 7. To improve the quality of life of patient. 23

24. NON-PHARMACOLOGICAL TREATMENT 1. Surgical intervention 2. Lifestyle modifications 3. Wound care 4. Nutritional support 5. Psychosocial support 24

25. FISTULOTOMY It is a surgical procedure used to treat anal fistulae. It is the most effective and common type of surgery that involves cutting along the whole length of the fistula to open it up to remove infected tissue and allow it to heal properly. 25

26. SETON TECHNIQUES Seton techniques are medical procedures performed by inserting a seton( a piece of material such as a silk or latex) inside the fistula tract to aid in draining abscesses heal completely. 26

27. LASER THERAPY Fistula laser treatment involves using a laser to destroy the fistula tract, which is an abnormal connection between two organs or vessels. A small probe is inserted into the fistula tract, and laser energy is delivered to the tissue along the path of the fistula. The laser energy destroys the tissue, causing it to seal and heal. 27

28. FISTULA PLUG Insertion of bioprosthetic plug. Cone shaped plug from animal tissue to block intestinal opening of fistula to promote healing. Less invasive than traditional surgery. 28

29. FIBRIN GLUE It is a medicinal adhesive that activates thrombin to form a fibrin clot that forms a clot and seals the fistula tract. Glue is injected into fistula under general anesthesia, after draining fistula. The glue seals fistula and helps it heal. Less effective than fistulotomy. 29

30. NUTRITION 73% of enteric fistulae closes spontaneously in adequately nourished patients, as against 19% in malnourished patients. Nutritional support needs to begin as soon as the patient is stabilized. Nutrition can be parenteral or enteral route, based on the anatomy of the fistula. Nutrition via the enteral route helps in maintaining the intestinal mucosal barrier, more efficacious delivery of nutrients, stimulating hepatic protein synthesis. TPN is also given in patients who do not tolerate enteral feeds or have long standing ileus or before fistulous tract is well established. 30

31. NUTRITION TYPE OF FISTULA CALORIE REQUIREMENT PROTEIN REQUIREMENT Low Output 30-35 kcal/kg/day 1-2 g/kg/day High Output 45-50 kcal/kg/day 1.5-2.5 g/kg/day 31

32. PHARMACOLOGICAL MANAGEMENT 1. Antibiotics will help fight against infection that if left untreated could worsen the patient’s condition. Commonly prescribed drugs include metronidazole and ciprofloxacin that may help reduce the discharge and promote comfort. 2. Immunosuppresive drugs used to manage inflammatory conditions contributing to fistula formation. Commonly prescribed drugs include azathioprine, it acts slowly therefore may take up to 3 months to show results. 32

33. PHARMACOLOGICAL MANAGEMENT 3. Pain relief medications help to reduce the pain and discomfort caused due to the fistula . 4. Somatostatin analogs - can be used to manage fistulas by reducing secretions from the digestive tract, which can help in closing the fistula and promoting healing. E.g. Octreotide 5. Topical Treatment- to promote healing and reduce inflammation depending on the type of fistula. 33

34. ANTIBIOTICS 1. Ciprofloxacin - 500mg orally 12 hourly Side effects-Gastrointestinal upset, tendonitis, nausea, diarrhea 2. Metronidazole - 400mg orally 8 hourly Side effects-Dry mouth, myalgia, nausea, oral disorders, metallic taste, vomiting, peripheral neuropathy 3. Clindamycin - 300mg to 450mg orally 6 hourly Side effects-Nausea, clostridium difficile infection 34

35. ANTIBIOTICS Metronidazole 400mg orally 8 hourly WITH Ciprofloxacin 500 mg orally 12 hourly Alternatively, Clindamycin 300 mg orally 6 hourly WITH Ciprofloxacin 500mg orally 12 hourly 35

36. ANALGESICS 1. Acetaminophen - 500-1000 mg orally every 4-6 hours (max 4g/day) Side effects- angioedema, dizziness, rash, urticaria, GI hemorrhage 2. NSAIDs - Ibuprofen 200-400 mg orally every 4-6 hours( not exceed 3200mg/day) Side effects- dizziness, nausea, constipation, rash, edema 3. Opioids - Tramadol 50-100 mg every 4-6 hours( not exceed 400mg/day) Side effects- constipation, nausea, headache, vomiting, dyspepsia 36

37. IMMUNOSUPPRESSIVE AGENTS For IBD-related fistulas 1. Azathioprine 2 -2.5mg/kg PO once daily. Side effects-Bone marrow depression, leucopenia, pancreatitis, thrombocytopenia 2. Mercaptopurine - starting dose of 1-1.5mg/kg PO once daily. Side effects- elevated LFTs, nausea, vomiting, stomatitis, diarrhea 3. Methotrexate- initially 25 mg once weekly until remission induced; maintenance 15 mg once weekly (IV/SC) or 10-25 mg once weekly (PO). Side effects- decreased appetite, leucopenia, fatigue, headache 37

38. SOMATOSTATIN ANALOGUES In your pancreas, somatostatin prevents or inhibits the release of pancreatic hormones including gastrin and pancreatic enzymes that aid in digestion. Example: Octreotide( Sandostatin ) Indicated for treatment of GI or Pancreatic Fistula. Solution: 50-200mcg SC every 8 hours for 2-12 days Side Effects: Diarrhea, abdominal discomfort, nausea and vomiting, sinus bradycardia, hyperglycemia. 38

39. TOPICAL PREPARATIONS Egs ; Topical antibiotics, Steroid creams 1. Topical antibiotics (e.g., mupirocin) : Apply a thin layer to the affected area 2-3 times daily. 2. Steroid creams (e.g., hydrocortisone) : Apply a thin layer to the affected area 2-4 times daily for a limited duration as directed. 39

40. ROLE OF THE PHARMACIST 1. Procure and ensure the proper handling and storage of medications used in the management of fistulas. 2. Ensure a rational use of antibiotics in order to help curb AMR. 3. Work together with the other healthcare providers to ensure optimum individualized therapy. 4. Educate patient on the appropriate use of their medications. 40

41. CONCLUSION Fistulae are complex medical conditions characterized by abnormal connections between organs and tissues. They can result from various causes including injury, infection or inflammatory or surgical created. Symptoms can vary widely depending on the location and severity of the fistula. Diagnosis often involves a combination of medical history, physical examination and imaging tests. Treatment options range from medical management to surgical intervention tailored to individual cases. While fi stulae can significantly impact the quality of life, timely diagnosis and appropriate management can improve outcomes and reduce complications. 41

42. REFERENCES British National Formulary (85th Edition) MEDSCAPE Britannica, The Editors of Encyclopedia : F istula. Encyclopedia Britannica ; https://www.britannica.com/science/fistula. Sharma, S.(2022) . Fistulae. available at https://www.1mg.com/diseases/fistula-927?wpsrc=Google+Organic+Search 42

43. THANK YOU 43