David
Co-Founder
I came across an interesting paper found here by Kate Willcutts about the management of fistulae via nutrition. The paper discusses enterocutaneous fistulas but I must state that it does not discuss them specifically in the context of those with Crohn's Disease so take that as you will. If you're not interested in reading the entire paper, here's some interesting tidbits I got from it:
- There are no well-established dietary or pharmacological treatment guidelines for enterocutaneous fistulas.
- There is a movement towards enteral nutrition rather than parental nutrition as it appears to help with the health of the intestinal mucosa and correlates with higher success rates when surgery is performed to repair the fistula. Factors that determine which to use include: where the fistula originates, how much healthy bowel is on each side of the fistula, volume of output and whether abdominal sepsis is present.
- Post-operative fistulas usually are seen within 7-10 days of the surgery.
- They feel a team approach should be utilized in the treatment of fistulas. The team would be comprised of: a physician, dietitian, wound ostomy continence nurse, pharmacist, and radiologist.
- There can be multiple tracts to a single fistula.
- Greater than 500ml of output per day is considered a high output fistula.
- One study found that waiting 3-6 months to surgically close a fistula resulted in the lowest refistulization rate.
- Patients with IBD are much less likely to experience spontaneous closure.
- Using radiological techniques is important to determine if there is also an abscess present as sometimes fever and increased WBC isn't present if the abscess has been "walled off".
- If there is an abscess, it should be drained prior to starting enteral nutrition.
- At the authors location, the first choice of EN is a polymeric formula. If that causes abdominal pain or diarrhea, they are changed to a semi-elemental. If that isn't well tolerated, they are switched to an elemental formula.
- They recommend intake of 1 liter per day of an electrolyte formula as well.
- Some clinicians feel that if the output of a fistula is greater than 500ml/day, then parental nutrition should be used instead of enteral nutrition. "As the volume of output increases, loss of electrolytes, proteins, bile salts, pancreatic enzymes and fluid can increase such that the patient’s nutritional status cannot be maintained without PN"
- Loperamide and codeine can reduce fistula output.
- There are no well-established dietary or pharmacological treatment guidelines for enterocutaneous fistulas.
- There is a movement towards enteral nutrition rather than parental nutrition as it appears to help with the health of the intestinal mucosa and correlates with higher success rates when surgery is performed to repair the fistula. Factors that determine which to use include: where the fistula originates, how much healthy bowel is on each side of the fistula, volume of output and whether abdominal sepsis is present.
- Post-operative fistulas usually are seen within 7-10 days of the surgery.
- They feel a team approach should be utilized in the treatment of fistulas. The team would be comprised of: a physician, dietitian, wound ostomy continence nurse, pharmacist, and radiologist.
- There can be multiple tracts to a single fistula.
- Greater than 500ml of output per day is considered a high output fistula.
- One study found that waiting 3-6 months to surgically close a fistula resulted in the lowest refistulization rate.
- Patients with IBD are much less likely to experience spontaneous closure.
- Using radiological techniques is important to determine if there is also an abscess present as sometimes fever and increased WBC isn't present if the abscess has been "walled off".
- If there is an abscess, it should be drained prior to starting enteral nutrition.
- At the authors location, the first choice of EN is a polymeric formula. If that causes abdominal pain or diarrhea, they are changed to a semi-elemental. If that isn't well tolerated, they are switched to an elemental formula.
- They recommend intake of 1 liter per day of an electrolyte formula as well.
- Some clinicians feel that if the output of a fistula is greater than 500ml/day, then parental nutrition should be used instead of enteral nutrition. "As the volume of output increases, loss of electrolytes, proteins, bile salts, pancreatic enzymes and fluid can increase such that the patient’s nutritional status cannot be maintained without PN"
- Loperamide and codeine can reduce fistula output.
