Management And Nursing Care Approaches To Entero Cutaneous Fistula (ECF)

Definition of Entero Cutaneous Fistula (ECF)

Fistula can present with devastating experiences which follow post operatively and often present as a secondary progression occasion from the primary abdominal pathology process. Focus of managing Entero cutaneous Fistula entails the fluid reflux, nutritional management, electrolyte imbalance and effluent management. In this review, ECF management is being discussed in depth with key focus on its diagnostic management of ECF, its assessments, nursing methods entailing its management and patient transfer process of ECF patients.

Entero Cutaneous Fistula is defined as an abnormal communication created between surfaces of epithelial cells. ECF refer to the communication created between the skin surfaces and rated based on their output. Those having drainage of over 500 ml in a day are referred to as high output fistulas, while those having 200 ml drainage per day  are referred to as low output drainage. Entero cute nous fistulas are a challenge in nursing care and have been linked to morbidity and disability as seen from patients exhibiting visceral malignancies, gastrointestinal problems and multiple surgeries of the abdomen, (Seeley, Chambers & Sandoval, 2015). ECF being managed post operatively can have serious complications. Statistics have indicated that about 90% of the ECF cases occur after surgical treatments, while there is 37% mortality rate occurring in cases exhibiting post operative high output.

Fistula can either develop early or later in the years which may be further be worsened after exposures of diabetes, pelvic surgery cases, hypertension or heart conditions. Fistula can have varied classifications grouped according to anatomic location or physiology.

ECF manifests itself to patients in varied ways; this can display itself inform of excess fluid from wound site or the cutaneous site. Further often skin disruption often occur and are located to the secondary level digestion of digestive system, symptoms associated include diarrhoea, mucus presence, blood, pneumatoria, presence of stool in the vagina and bowel discomfort, (Joyce & Dietz, 2009).

Resulting factors of ECF are often myriad, in that it can include surgical processes, patient co-rmobidities, and accidental pathology of the body and often they are unwanted. The challenges exhibited by ECF, have shown to explicit challenges to both the patients and the nurses which raises the burden of health care to both the health care system and the patients, (Folland, & Goodman & Stano, 2016).

Occurrences of ECF normally occur after operative procedures thus referred to as iatrogenic. The typical characteristically are the missed surgeries which occur on the bowel section during surgical procedures, disruption and leakages are linked to surgical type of ECF. Good standard operating procedures to surgery and safe practices to bowel sections, avoiding tension and proper use of ileastomes are good practices towards avoiding ECF.

Manifestations of ECF

Diagnostic test often performed involve the patient being stabilized and the ECF being controlled. Then there is need for determination of pelvic abscess or the associative abdominal presence, which brings into focus the fistula anatomy. In the diagnostic tests the key focus of concentration is determining the location of the fistula, (Kwon et al, 2008).

Performance of computed tomography or the magnetic resonance imaging, endoscopy and fistulography diagnostics tests can be performed. Computed Tomography and magnetic resonance are often the most valuable tests to show case the extra intestinal and intestinal pathology observations, (Siddiqui et al, 2017). 

As far as CT has been touted as easily available, less expensive and costly easy usability, it is often difficult to establish the fistulous tracts which the MRI are able to define confidently. MRI diagnosis is the best recommended avenue for these assessments, (Bartram & Buchanan, 2003). Its accuracy in determination and evaluation on ECF is vague. ECF occasioned with abdominal abscess, treatment is offered intravenously using antibiotics and drainage entailing percutaneous sites need to be taken care of effectively. Size of ECF is taken using a fistulography assessments tests are undertaken, (Kwon et al, 2008).

Laboratory assessments

Lab tests do not comprehensively confirm presence of fistulas, but rather they are important definition of the clinical presentations of the patients and guides also the treatment processes. Often complete blood count (CBC) is obtained, indicative status signalling the presence of high levels of white blood cells count, depicts a linked infection. Soft tissue, abscessed and infection aligned to entercutenous fistula, blood stream and infection can display itself. Nutritional deficit patients who are elderly many portray increased levels of White Blood Cell count being indicative of infections, (Schecter et al, 2009).

Assessment of electrolyte levels is critical in establishing the imbalance and dehydration which are common among patients. Incidences of hypokalemia, metabolic alkalosis and hypochlorema have been note among patients having high output ECF. Further patients with pancreatic and bowel fistulas are often linked to hyponatremia  and metabolic acidosis.

Serum Albumin assessments

Serum albumin levels have been used as an indicator of assessing fistula closure and its mortality. Studies done have shown that serum albumin levels greater than 3.5mg/dl was linked with no mortality case while those below 2.5 mg/dl were associated with 42% of mortality cases. Patients exhibiting bacteria and septic cases have been shown to have positive blood result findings. The blood culture results are often a direct anti biotic therapy on the organisms.

Diagnostic Test

Imaging assessments

CT scans allows for identification of drainage process which is linked to fluid collection and identification of fistula site; Computed Tomography having oral contrast signify fistula site. Duodenal, gastric and proximal bowel fistulas can be identified easily. Distal bowel obstruction presence or absence can be revealed in this method, (O’Malley et al, 2015).

Performance of fistulography is often confirmed by the location of Entero cutanous fistula. The drainage fistulas are often located in the radiologic guidance in order to remove the abscesses. If on observation the drainage contents are enteric, draining allows for tract forming.

Stabilization of the patient is done in the correct form of electrolyte imbalance and administering antibiotics drugs, soluble contrast of the drainage is thus infused using a catheter or during the CT scan process.

Assessment of small bowel contrast on radiography signifies enter enteric fistula among patients having chrohn disease. This yields complaints such as abdominal pain; cramping anorexia which all are symptomatic signs displaying primary and inert fistulas in the body, (Consigny et al, 2016).

Oral administration of activatedcharcoal

The activation of oral charcoal signifies the presence of granules in fluid discharge of fistula and confirms the presence of ECF. Charcoal particles appearance in vaginal and urinal discharge is an indicative measure of enterovesical fistula.

Ethylene Blue Oral administration

Emergence of dye, incision, skin defects and drain often reflects the presence of ECF. Methyl administrations further can portray enterovessical fistula and enterovaginal fistula presence. The surgical literature has enlisted ethylene blue as an assessment tests, however it has been associated with patients deaths, thus it is not a recommended avenue for investigation on the presence of fistula on patients.

Pseudo stoma and the significance of this development

Pseudo stoma is an opening of cell membrane due to defection on staining. In fistula cases, it is referred to as stomatized fistula, which occurs in epithelial cells, which occurs when the anterior wall on the section of the bowel that needs surgical closing. It is significant in fistula management, as it can cause rupture and cause infection on the site hence needs critical attention, (Braynt & Best, 2015).

Presence of mesh in ECF

Fistula management needs to incorporate the use of ECF effluent through pouching and skin protectio0n measures. This is often with opening of abdomen, sepsis which cannot be managed are often key determinants of recovery. Often CT scan is performed for these patients for the initial management on patients having abdominal abscess., (Bostanci et al, 2015)

Management Approaches of ECF

Complications which arise from the ECF include wedge repair and bypass repair have been medical strategies used. In reducing these complications, primary abdominal wall closure has often been used as the best method to manage it, (Wind, Koperen & Behelman, 2009).

Various types of meshes have been developed to maximize the abdominal wall repair defects; these are classified according to sizes of the pore and material texture which is based on different polymers. The mesh can have absorbable or non absorbable characteristics. Those that are not absorbable have long lasting durability; its application however is characterized by increased risk of infection due to the abdominal contamination, (AlSubaie et al, 2015).

Prior to operations process, often there is lack of sufficient momentum which is linked both the mesh and bowel for preventing mesh changes which exposes bowel, (Huang & Lau, 2016). Thus the use of Mesh on ECF management has been rated highly, however despite its usage; it is still linked to complications such as adhesions formation, bowel obstruction and fistula emergence, (Connolly et al, 2008).

Recently new advances of new prostheses to maximize the treatment plan and large abdominal wall have effects. The meshes have core component which provides non absorbable resistant and secondary components for bowel adhesions. Efforts of having both types of meshes have rapid integration and cover to ensure there is prevention of adhesion and intestinal fistulae.

Nursing care approaches as Certified Enterostomal Therapy Nurse (CETN)

Caring for patients with entero cutaneous fistula is often complicated and portrays challenges to the nursing care. Effective management entails a holistic assessment of the patients, (Kumpf et al, 2017). Determining the roles and goals of nursing and effective management of patients with ECF is often contingent and acknowledgement of the systematic factors and accurate assessments which include itself assessment, skin contours and wound healing traits.

Patient variables include maintaining patient stability and the impact of the quality of life the self image assessment, (Lauro et al, 2017). The comprehensive assessment of ECF is often lacking and has shown to impact on the quality of care. Nursing approaches entail characterization of physical and local factors, care of the community and patient related factors.

Often documentation in care management is critical for patient assessment and ensuring monitoring of progress of health of the patient. Reassessing all factors of the patients is critical in ensuring that goals of care are reevaluated and undertaken in a timely manner, (Cruz et al, 2017). 

Complications of ECF Management

Nursing management for nurses cannot be successful without the collaboration of other personal and members of medical care team. Each team has the role of ensuring that comprehensive patient information is shared across the medical team.

Effective nursing methods for ECF management include the following;

Assessment

Determination of the type of fistula is critical in care process. As a nurse there is need to identify the type of fistula a patient has, this include abdominal contours, opening of the fistula, characteristics of effluent and the condition of underlying fistula skin. Dressing chances and pouch management show case the opportunities which are aimed at evaluating and modifying care plans. Assessments, interventions and various management plans need to be documented.

Various documentation by nurses includes;

• Assessing fistula source
• Pain assessment
• Opening of the fistula
  • Location
  • Width and length and
  • Height
• Fistula skin integrity
  • Assessing its intact status
  • Impaired ness
• Contours present in abdominal section which is proximal to skin  folds, drains or other ostomies
• Volume of output content
  • Entailing the volume
  • Consistency
  • Colour and
  • Odour
• Interventions
  • Nurses providing emotional support
  • Care process rational
  • Educating family or patient
• Evaluation
• Follow up plan

1. Assessing progress and challenges towards spontaneous closure

A critical assessment tool in the evaluation process and evaluation of spontaneous closure are assessed through the volume assessment of fistula tract and increase of faecal output content. The output of the fistula should be monitored. Formation of abscess and abdominal tenderness needs to be assessed, (Huang et al, 2017). As nurse it is critical to be always alert sp as to ensure that development of stoma fistula referred to as pseudo stoma, which often occurs on the anterior wall in the bowel. Factors which need to be considered in nursing strategy include;

• Obstruction of the distal
• Tumour presence
• Site irradiation site if present, abscess
• Hematoma
• Crohn disease
• Fistula foreign body presence
• In effective distal suture line
• Effluent characteristics

Assessing the characteristics of effluent is critical in determining the source and topical management is critical in nursing techniques. Assessing into insight of the degree and risk of peri fistula skin breakdown is key in ensuring that the closure is closed

The characteristics of effluent, in terms of odurs and production of semi formed consistency are sourced from the colon, which prevents damage on the skin. the key role of this is ensuring that there is topical management of effluent and odour control.

ECF Output greater than 100ml in a 24 hour period requires a pouch or suction, while ECF with low volume output is easily managed with moisture barrier and a dressing capable of absorbing, (Reddi, 2018).

However in low output patient can require a pouch in order to control odour. Odour can originate from varied sources which include faecal output, tissue infection or chemical use in the treatment phase.

Advantages and Disadvantages of nursing strategies

Nursing strategy	Advantages	Disadvantages
ECF Nursing Assessment	– Effective for appropriate treatment – Objective treatment formulation – Assessment of appropriate intervention	– Complicated cases for assessment which is coupled with infection – Requires adequate nursing skills – Nursing experiences plays role in effective assessment
Assessing progress and challenges towards spontaneous closure	– allows for convex pouching on fistula emptying on the skin – effective for assessment of abscess drainage – allows for skin contours	– large pannus often portray nursing challenges – occurrence of irregular skin observation – fistula emptying on the skin
Effluent characteristics assessments	– management of odour – determination of type of  pouch closure  needed – assessing of the fistula effluent volume	– management can be challenging when pouch and sunction technique are needed – variances of effluent volume affects characterization of effluent – effluent mixture can lead to infection if not managed well

Nursing management for the patient

Patient John requires a conservative management with an overall objective of helping the physical and providing psychological support for the patient. Adherence to principle of nursing management is critical.

Nursing Care Approaches as CETN

Total parental nutrition needs to be followed up coupled up with vacuum assisted closure and glue management by fibrin in order to decrease the output and aid in spontaneous closure of the fistula. Treating the patient with Somatostatin is effective as it is peptide hormones which has inhibitory effects on the GI secretion and used commonly in gastrointestinal hormones and reduce blood flow and inhibit contraction, (Roan et al, 2016).

Further the patient can be provided with nutritional supplements as the gastrointestinal secretion are halted by 30-50% on TPN which aides the closure of the fistula. Thus nutritional support is key towards managing the nutritional needs of the patient towards healing process, (Kumpf et al, 2017). 

Further ensuring electrolyte balance will be key in ensuring that the patient maintains normal levels of potassium, chloride and bicarbonate is key as it aides healing process.

Transfer care sheet

With the challenges of the entero cutaneous fistula opining on the belly and leaking the contents out, effective care managed needs to be initiated. Normal healing process of fistula is approximately 2-8 weeks without any form of treatment. However with drug treatment and special diets, recovery may be achieved. 

Home care needs an effective care process and clear discharge instructions. The discharge instructions for home care healing phase are illustrated below;

Discharge care	Rationale
Fluid management – drink 6-8 glasses of water – wear pouch effectively for liquid drain – manage other health conditions	– Water management is crucial for balancing the electrolyte imbalance which might occur
Anti biotic drug management – strict follow up on medication regiment	– Prescription and follow up of drug is key to prevent infection, managing pain swelling, electrolyte replacement and protection of the skin within the fistula
Limiting physical activities	– Avoiding physical activity is key so as not to allow straining of the wound as it heals.
Nutrition care – total liquid diet – total parental nutrition – IV line food management if possible	– The bowel site needs rests hence consumption of heavy foods needs to be delayed and given green light after medical assessments.
Seeking medical attention on observation of ; – Signs of infection occasioned by high fever – Stomach upsets – Fistula drainage reoccurrence – Abnormal heart beats	– These are signs of complications hence any observation needs medical attention.
Education support – Providing life quality through community health nurse	– This is a crucial phase in care management and treatment plan for the patient. Patient and family education for the patient should be individualized in order to regain control of managing the disease.

Conclusion

Thus fistula management is complex and yet a delicate process which needs critical nursing skills to manage stoma associated complications. The various diagnostic tests and assessment tests for the patients are aimed at improving the care process of the patients. Effective care process for patient John, will go a long way in helping him to adopt and adjust to the treatment regimes. The transfer care process is critical for the patient to have a successful transition at home. 

References

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