Overview
Definition:
A gastrocutaneous fistula is an abnormal opening between the stomach and the skin, allowing gastric contents to leak externally
After percutaneous endoscopic gastrostomy (PEG) placement, a gastrocutaneous fistula refers to persistent leakage or an unintended opening at the PEG site that fails to close spontaneously after device removal or discontinuation.
Epidemiology:
The incidence of persistent gastrocutaneous fistulas after PEG removal is relatively low, generally reported between 1-3%
Risk factors include malnutrition, immunosuppression, prolonged PEG use, and complications at the insertion site such as infection or irritation.
Clinical Significance:
Persistent gastrocutaneous fistulas can lead to significant morbidity, including malnutrition due to leakage of gastric contents, skin breakdown and infection, electrolyte imbalances, and psychological distress for the patient
Prompt and effective management is crucial for patient recovery and quality of life.
Clinical Presentation
Symptoms:
Persistent leakage of gastric fluid or bile from the PEG site after device removal
Skin irritation, maceration, and erythema around the stoma
Foul odor from the drainage
Inability to initiate oral feeding due to persistent leakage
Signs of dehydration or malnutrition in severe cases.
Signs:
Visible stoma opening at the gastrostomy site
Continuous drainage of gastric contents onto dressings
Evidence of cellulitis or abscess formation around the stoma
Palpable induration or granulation tissue at the fistula tract
Poor wound healing.
Diagnostic Criteria:
Diagnosis is primarily clinical, based on the persistent drainage of gastric contents from the stoma site for more than 2-3 weeks after PEG removal or discontinuation
Confirmation may involve a contrast study of the fistula tract to assess its size and depth, or endoscopic evaluation.
Diagnostic Approach
History Taking:
Detailed history of PEG placement, duration of use, and any complications during its indwelling period
Previous attempts at closure
Nutritional status and oral intake capabilities
Co-morbidities, especially those affecting wound healing or immune function
Any signs of infection or systemic illness.
Physical Examination:
Careful inspection of the stoma site for erythema, edema, induration, and discharge
Assess the surrounding skin for maceration or breakdown
Palpate the tract for any tenderness or induration
Evaluate the patient for signs of dehydration or malnutrition.
Investigations:
Contrast fistulography: A contrast medium is injected into the fistula tract and serial X-rays are taken to delineate the tract's course, size, and communication with the stomach
Endoscopy: Can visualize the gastrocutaneous opening from the gastric side and assess the integrity of the gastric mucosa
Laboratory tests: Complete blood count (CBC) to assess for infection, electrolytes, albumin to assess nutritional status.
Differential Diagnosis:
Simple wound dehiscence at the stoma site without persistent fistula formation
Skin breakdown due to gastric acid irritation without a true tract
Enterocutaneous fistula from other abdominal pathology
Abscess or cellulitis at the PEG site.
Management
Initial Management:
Conservative management is the first-line approach
Meticulous wound care with frequent dressing changes
Application of barrier creams or ostomy pastes to protect the surrounding skin from gastric secretions
Nutritional support optimization, either via parenteral nutrition or if possible, through an alternative oral or enteral route
Identification and treatment of any superimposed infection.
Medical Management:
Proton pump inhibitors (PPIs) may be used to reduce gastric acidity, potentially aiding in spontaneous closure
Antibiotics are indicated if there is evidence of local infection or cellulitis
Nutritional support should be optimized.
Surgical Management:
Surgical intervention is considered for persistent fistulas that do not close with conservative measures, typically after 4-8 weeks of conservative therapy
Options include: Simple Ligation and Excision: For small, superficial fistulas
Fistula Excision with Gastric and Cutaneous Closure: The fistula tract is dissected and excised, followed by layered closure of the gastric wall and the abdominal wall defect
Gastric Resection: In cases of large or complex fistulas involving significant gastric wall defect, a partial gastrectomy may be necessary
Minimally Invasive Techniques: Laparoscopic approaches may be used for fistula excision and closure in select cases.
Supportive Care:
Pain management
Regular monitoring for signs of infection
Psychological support for the patient
Close follow-up by a multidisciplinary team including surgeons, gastroenterologists, dietitians, and stoma nurses.
Complications
Early Complications:
Worsening skin breakdown
Cellulitis or abscess formation at the stoma site
Dehydration and electrolyte disturbances due to persistent leakage
Increased risk of malnutrition.
Late Complications:
Scarring and cosmetic deformity
Adhesions if laparotomy is performed
Recurrence of the fistula after attempted closure
Chronic skin irritation or dermatitis.
Prevention Strategies:
Proper PEG insertion technique and fixation
Regular stoma site care and monitoring
Prompt management of any early complications like infection or irritation
Adequate nutritional support during and after PEG use
Judicious use of PEG, considering alternative feeding methods when appropriate.
Prognosis
Factors Affecting Prognosis:
Size and depth of the fistula
Duration of leakage
Patient's nutritional status and immune function
Presence of comorbidities
Success of initial management strategies
Extent of surgical intervention required.
Outcomes:
Most small gastrocutaneous fistulas after PEG will close spontaneously with conservative management
Larger or persistent fistulas requiring surgical intervention generally have good outcomes with complete closure, although recurrence is possible
Patients with underlying severe malnutrition or immunosuppression may have poorer outcomes.
Follow Up:
Close follow-up is essential to monitor for signs of recurrence or complications
This typically includes regular clinical assessments, wound checks, and nutritional status evaluation
For surgically managed fistulas, follow-up continues until complete wound healing and functional recovery.
Key Points
Exam Focus:
Recognize the common presentation of a persistent gastrocutaneous fistula post-PEG
Understand the indications for conservative vs
surgical management
Be familiar with the surgical techniques for fistula closure and their potential complications.
Clinical Pearls:
Always consider conservative management first for post-PEG fistulas, focusing on meticulous wound care and nutritional support
Contrast fistulography is a key investigation to delineate the tract
Surgical excision and layered closure is the definitive treatment for refractory fistulas.
Common Mistakes:
Prematurely opting for surgery without adequate conservative trial
Underestimating the importance of skin care and nutritional support
Inadequate assessment of fistula tract size and depth
Failing to identify and manage underlying factors contributing to poor wound healing.