Gastric fistula: symptoms and treatment
A gastric fistula is a canal that is located in an atypical place of the stomach and connects it with other organs, or with the skin.
Sometimes doctors create a gastric fistula artificially in order to achieve a particular therapeutic goal. For example, when food cannot pass through the esophagus and requires direct administration.
Content:
- What is a gastric fistula? Types of fistulas
- Reasons for the formation of fistulas
- Pathogenesis of gastric fistula
- Stomach fistula symptoms
- Complications of the fistula
- Diagnosis of gastric fistulas
- How is gastric fistula treated?
- Prevention of the formation of a gastric fistula
- Forecast
What is a gastric fistula? Types of fistulas
Pathological fistulas in the stomach are rare. If they are formed, then most often they do not go outside, but connect the stomach with other organs. When performing an operation for peptic ulcer disease, such fistulas are diagnosed in 10-30% of cases. As for the pathological fistulas that connect the stomach to the skin, they are detected only in 0.5% of cases.
The greatest danger is posed by such channels that are formed against the background of purulent complications in the following categories of patients:
- Elderly patients.
- Immunocompromised patients.
- Patients with diabetes mellitus.
- Cancer patients who have received radiation or chemotherapy.
It should be understood that gastric fistula is a problem that affects not only the diseased organ itself, but also the state of the body as a whole.
There are the following types of gastric fistulas:
- External, while the stomach through the fistulous canal communicates with the external environment. The mouth of the fistula is attached to the skin.
- Internal, while the stomach communicates through the fistula with other internal organs. Most often, fistulas grow into the small or large intestine, into the bile duct, although other options are possible.
Reasons for the formation of fistulas
Pathological fistulas never form on their own. They always occur against the background of any disease of the digestive system.
The main reasons for the formation of a fistula of the stomach are the following:
- Violation of the technique of applying surgical sutures during surgery on the stomach.
- Purulent inflammation, accompanied by the destruction of organ tissues. This process can be started both before the operation and after it.
- Obstruction of the anastomosis between the stomach and other organs.
- Stomach cancer.
- The presence of a foreign body in the stomach cavity or in its wall.
- Oxygen starvation of the stomach tissues, which develops against the background of a violation of the blood supply to it. As a result, one of the parts of the organ is deprived of nutrition, which leads to the death of its tissues.
- Radiation exposure.
- A technical error of the surgeon during the operation.
- Violations of the rules of patient care in the postoperative period.
In the vast majority of cases, fistulas form between the stomach and intestines, or between the stomach and pancreas and / or bile ducts.
Anastomotic ulcer is the main cause leading to the formation of an internal gastric fistula. A pathological canal is formed most often after a gastric resection (surgery to remove a part of an organ), or when an artificial anastomosis is placed between the stomach and intestines.
Fistula, in the overwhelming majority of cases, originates from the stomach, paving the way to other tissues. From other organs of the digestive system, fistulas rarely stretch to the stomach.
Reasons for the formation of external fistulas:
- Divergence of sutures after an artificial anastomosis is applied between the stomach and intestines;
- Formation of a gastrostomy that connects the stomach to the peritoneal wall;
- Operation on the lesser curvature of the stomach.
Risk factors, which in themselves are not capable of leading to the formation of a fistula, but can speed up the onset of the reasons leading to its development:
- Chronic course of diseases of the digestive system;
-
The presence of a hidden infection in the body;
- Injury to the abdomen, which may be the result of injury, injury, surgery, hemorrhage in the gastric wall;
- Violation of the technique of the operation or an incorrectly selected type of surgical intervention.
Operations that most often lead to the formation of gastric fistulas:
- Secondary intervention in the peritoneal cavity in order to remove adhesions;
- An operation that is performed after an injury to the abdomen;
- Operations for the removal of a hernia;
- Diagnostic or therapeutic laparoscopy;
- Formation of anastomosis in case of stomach or intestinal cancer, or gastric ulcer;
- Operation on the biliary tract.
Pathogenesis of gastric fistula
A fistula is formed when the integrity of the gastric wall is violated and its contents, which have an acidic environment, begin to seep into the tissue, corroding them. As a result, a channel is formed. Moreover, it can be directed both towards other organs and towards the anterior abdominal wall.
There are two forms of gastric fistula: labial and tubular.
The lip-shaped fistula does not have a canal; its mouth is soldered to another organ or to the skin. Such fistulas do not heal by themselves, so a person needs surgery.
The tubular fistula is represented by an oblong canal, which is covered with an epithelial layer inside. If pathological contents cease to pass through such a fistula, then it can tighten on its own.
They also distinguish between formed and unformed fistulas. The formed channels have an opening and walls. An unformed fistula is characterized by tissue necrosis, the presence of a molten gastric wall, but the absence of the canal itself.
External unformed fistulas stand apart. In this case, the skin and the mucous wall of the stomach are fused with each other, but not completely. In parallel, pathological pockets can form, into which the contents of the stomach begin to flow, including with pus. Treelike fistulas that have multiple channels are rarely diagnosed. Also, in medical practice, single and multiple fistulous passages are distinguished.
Stomach fistula symptoms
The following symptoms will indicate an external fistula:
- The presence of an opening on the wall of the peritoneum, it will be located opposite the stomach;
- Macerated skin in the area of fistula formation;
- The presence of discharge from the formed course, it can be foamy, or be particles of eaten food.
As for the symptoms of an internal fistula, they depend on which organ it connects to the stomach. However, it is difficult not to notice their development, since they make themselves felt already at the stage of development. The fact is that the process of formation of a pathological channel will be preceded by erosion of the mucous membrane and muscle tissue of the stomach. This is always accompanied by sharp pains that resemble the pain of a perforated stomach ulcer. In addition, a person may vomit, and the general well-being will greatly deteriorate, and symptoms of body poisoning will increase.
Symptoms of a fistula that has formed between the stomach and small intestine:
- Uncontrolled diarrhea;
- The appearance of fat particles in the feces.
When intestinal contents begin to flow into the stomach through the fistula, the patient's condition deteriorates significantly.
Symptoms of fistula formation between the stomach and the large intestine:
- The appearance of the smell of feces from the oral cavity;
- The appearance of belching and vomiting, the smell of stool will come from the masses;
- In severe cases, vomiting of feces is possible;
- Diarrhea.
The human condition worsens as a whole, as there is a violation of the migration of nutrients in the organs of the digestive system. The patient begins to lose weight, he has a subfebrile body temperature for a long time.
The body will gradually poison itself, which is expressed by the following symptoms:
- Apathy;
- Drowsiness;
- Headache;
- Depression tendency.
The symptoms of a gastric fistula will be the stronger, the larger the size of the formed pathological canal. In addition, the patient's condition will be worse when the fistula forms between the stomach and the large intestine (in comparison with the clinic of the fistula of the stomach and small intestine).
Complications of the fistula
Distinguish between local and general complications of gastric fistula.
Local complications include:
- Inflammation of the skin, the development of dermatitis;
- Suppuration of the skin at the site of fistula formation;
- The appearance of bloody discharge from the fistula.
If suppuration of the skin occurs, this can be expressed in boils (the hair follicle of the skin and sebaceous gland becomes inflamed due to the ingress of stomach contents into them), in carbuncles (several sebaceous glands and hair follicles are inflamed at once), in phlegmons (extensive purulent inflammation).
Internal fistulas can lead to the development of the following complications:
- Acute and chronic enteritis (the wall of the small intestine is inflamed);
- Acute and chronic colitis (the wall of the large intestine is inflamed);
- Formation of an abscess;
- Flow of purulent contents into the peritoneal cavity.
In addition, the body as a whole will suffer from the following complications of an internal fistula:
- The water-salt balance is lost;
- Protein metabolism suffers;
- The person is losing weight.
Diagnosis of gastric fistulas
As for the external fistula, its diagnosis is not difficult. A pathological opening is visualized in the skin, from which the gastric contents exit.
The presence of an internal fistula can be suspected by the symptoms it gives. However, with small fistulas, it is not always possible to detect their presence only by the clinical picture, since it appears rather blurred. The doctor may suspect the presence of an internal fistula in the case when a patient with complaints of abdominal pain has recently undergone surgery on the stomach, or an anastomotic ulcer has been identified.
During the examination of the patient, the doctor can detect the following indirect signs indicating a pathological formation in the stomach:
- Dry skin, reduced turgor. This symptom is characteristic of a progressive disease, which has already led to a violation of the water-salt balance.
- During palpation of the peritoneum, the patient will complain of painful sensations.
- Sound changes when tapping the peritoneal wall.
- Intestinal noises and bursts are heard while listening to the abdomen. In this case, the intestine itself will be at rest.
To make the most accurate diagnosis, the patient will be sent to undergo the following examinations:
- X-ray contrast examination of the stomach. If the patient has a fistula, the contrast agent will enter his cavity and illuminate the canal on an X-ray image. The doctor will see that the gastric masses come out not only through the natural opening, but also through the pathological canal.
- Dynamic gastric scintigraphy. During the study, the doctor will be able to estimate the speed of passage of food masses, which will be illuminated by a radioisotope.
- FGDS - examination of the mucous membrane of the stomach and duodenum using endoscopic equipment.
- Intestinal scintigraphy is static. This study will assess intestinal patency. The patient will need to take a drug that will be labeled with a radioisotope.
If a person has an external fistula, then he is shown the passage of fistulography. In this case, a contrast agent is injected into the fistula canal, after which the doctor takes a series of X-ray images. This method makes it possible to clarify the direction of the fistula, its length and diameter, and the presence of skin pockets.
In order to assess the general condition of the body, the patient is shown the delivery of laboratory tests: general and biochemical blood tests. An increase in the growth of ESR and leukocytes in the blood will indicate the presence of inflammation. The albumin level is called to assess the possibility of self-closure of the fistula (an indicator of more than 3.5 mg / dL - a good prognosis, a level of less than 2.5 mg / dL - the probability of death is 40%).
Differential diagnosis
As a rule, a differential diagnosis is required in the presence of an internal fistula.
It is important to distinguish it from the following diseases:
- Calculous cholecystitis in the acute stage, as well as cholecystitis, not accompanied by the formation of stones;
- Inflammation of the pancreas;
- Interintestinal abscess;
- Inflammation of the peritoneum;
- Peptic ulcer of the anastomosis;
- Phlegmon of retroperitoneal tissue;
- The presence of a fistula between the intestine and other organs, and not the stomach.
How is gastric fistula treated?
The fistula can grow on its own. However, this will require conservative therapy aimed at eliminating the cause that provoked its formation. In some cases, it is impossible to do without surgical intervention.
Conservative treatment solves the following tasks:
- Elimination of the cause of the formation of a fistula so that it closes without surgery;
- Preparing the patient for surgery, if the fistula cannot be treated without it;
- Transfer of an unformed fistula to a formed one.
It should be understood that even conservative treatment of a fistula requires admission to a hospital.
It boils down to the following activities:
- Transfer of the patient to parenteral nutrition. The patient will not receive food through the mouth.
- As an alternative to parenteral nutrition, it is possible to form a jejunostoma, when the patient's jejunum is surgically sewn to the peritoneum and a hole is made in it. Through it, a person is injected with food, bypassing a sick stomach.
- Infusion therapy. On a dropper, the patient is given protein fractions, saline and electrolyte solutions, possibly an infusion of blood serum.
- Prescribing antibacterial treatment. This will eliminate existing infections, or prevent the development of new inflammation.
- If the patient has an external fistula, then an important measure is the treatment and protection of the skin from caustic gastric juice.
Surgical intervention is reduced to excision of the fistulous canal and plastic surgery of the stomach. The most favorable prognosis will be when the fistula is cut out no later than 2 months after its formation. However, it will not be possible to do without the appointment of antibiotics and infusion therapy.
Prevention of the formation of a gastric fistula
In order to prevent the formation of a fistulous canal, it is necessary to deal with the reasons that lead to its development.
In this regard, the following activities will be effective:
- Timely treatment of stomach and intestinal ulcers.
- Qualitative elimination of anastomotic obstruction.
- Cancer treatment.
- Avoiding mistakes by the surgeon during operations on the stomach.
Naturally, it would be better to prevent the development of these diseases than to treat them in the future.
Forecast
As for the prognosis for gastric fistula, in about 25% of cases, the death of patients occurs, which happens due to a violation of the digestive process. The situation is complicated by the fact that many patients do not give any specific complaints, or do not come to see a doctor at all. Even when a person gets a preventive examination by a doctor, it will be quite problematic to establish the correct diagnosis, especially if there is an internal fistula.
The author of the article: Volkov Dmitry Sergeevich | c. m. n. surgeon, phlebologist
Education: Moscow State University of Medicine and Dentistry (1996). In 2003 he received a diploma from the Educational and Scientific Medical Center of the Presidential Administration of the Russian Federation.
