Fistula

From WikiProjectMed

Abnormal connection between two epithelialized surfaces, often organs

This article is about the anatomical term. For the former legume subgenus, seeCassia (genus). For the metal straw used in Catholic liturgy, seeFistula (liturgical object).

Not to be confused withVistula.

Medical condition

Fistula

AbdominalCT scan with right colocutaneous fistula and associated subcutaneouspneumatosis
Pronunciation	/ˈfɪstjʊlə/^[1]^[2]
Specialty	General surgery

Inanatomy, afistula (pl.:fistulas orfistulae /-li,-laɪ/; fromLatinfistula, "tube, pipe") is an abnormalconnection (i.e. tube) joining two hollow spaces (technically, twoepithelialized surfaces), such asblood vessels,intestines, or other holloworgans to each other, often resulting in an abnormal flow of fluid from one space to the other.^[2]^[3]^[4] Ananal fistula connects theanal canal to theperianal skin. An anovaginal orrectovaginal fistula is a hole joining the anus orrectum to thevagina. A colovaginal fistula joins the space in the colon to that in the vagina. A urinary tract fistula is an abnormal opening in theurinary tract or an abnormal connection between the urinary tract and another organ. An abnormal communication (i.e. hole or tube) between thebladder and theuterus is called avesicouterine fistula, while if it is between the bladder and the vagina it is known as avesicovaginal fistula, and if between theurethra and the vagina: a urethrovaginal fistula. When occurring between two parts of the intestine, it is known as an enteroenteral fistula, between thesmall intestine and the skin it is known as an enterocutaneous fistula, and between the colon and the skin as a colocutaneous fistula.^[3]

A fistula can result from an infection, inflammation, injury or surgery.^[5] Many result from complications during childbirth. Sometimes a fistula is deliberately surgically created as part of a treatment, for example in the case of anarteriovenous fistula forhemodialysis.^[6]

The treatment for a fistula varies depending on the type, cause, and severity of the fistula, but often involves surgical intervention combined withantibiotic therapy. In some cases the fistula is temporarily covered using a fibrin glue or plug. A catheter may be required to drain a fistula.^[3]

Globally, every year between 50,000 and 100,000 women are affected by one or more fistulas relating to childbirth.^[7] Typically they are vaginal fistulas, between either the bowel or bladder and the vaginal canal, but uterine and bowel fistulas also occur.

Inbotany, the term is most common in its adjectival forms, where it is used inbinomial names to refer to a species that is distinguished by one or more hollow or tubular structures.Monarda fistulosa, for example, has tubular flowers.^[8]

The term was first used in the 14th century.^[2]

Definition

A fistula is an abnormalconnection betweenvessels ororgans that do not usually connect. It can be due to a disease or trauma, or purposely surgically created.^[3]^[5]

Classification

Various types of fistulas include:

Blind: Only one open end; may also be called sinus tracts.^[5]
Complete: Both internal and external openings.^[5]
Incomplete: An external skin opening that does not connect to any internal organ.^[5]

Although most fistulas are in forms of a tube, some can also have multiple branches.^[9]

Location

Types of fistula can be described by their location. Anal fistulas connect between the epithelialized surface of the anal canal and the perianal skin. Anovaginal or rectovaginal fistulas occur when a hole develops between the anus or rectum and the vagina. Colovaginal fistulas occur between the colon and the vagina. Urinary tract fistulas are abnormal openings within the urinary tract or an abnormal connection between the urinary tract and another organ such as between the bladder and the uterus in a vesicouterine fistula, between the bladder and the vagina in a vesicovaginal fistula, and between the urethra and the vagina in urethrovaginal fistula. When occurring between two parts of the intestine, it is known as an enteroenteral fistula, between the small intestine and the skin as an enterocutaneous fistula, and between the small intestine and the colon as a colocutaneous fistula.^[3]

The following list is sorted by theInternational Statistical Classification of Diseases and Related Health Problems.

H: Diseases of the eye, adnexa, ear, and mastoid process

(H04.6)Lacrimal fistula
(H05.81)Carotid cavernous fistula
(H70.1)Mastoid fistula
- Craniosinus fistula: between theintracranial space and aparanasal sinus
(H83.1)Labyrinthine fistula
- Perilymph fistula: tear between the membranes between the middle and inner ears
Preauricular fistula
- Preauricular fistula: usually on the top of thecristae helicis of the ears

I: Diseases of the circulatory system

(I25.4)Coronary arteriovenous fistula, acquired
(I28.0)Arteriovenous fistula ofpulmonary vessels
- Pulmonary arteriovenous fistula: between an artery and vein of thelungs, resulting inshunting of blood. This results in improperly oxygenated blood.
(I67.1) Cerebralarteriovenous fistula, acquired
(I77.0)Arteriovenous fistula, acquired
(I77.2) Fistula ofartery

J: Diseases of the respiratory system

(J86.0)Pyothorax with fistula
(J95.0)Tracheoesophageal fistula, between thetrachea and theesophagus. This may becongenital or acquired, for example as a complication of atracheostomy.

K: Diseases of the digestive system

(K11.4)Salivary gland fistula
(K31.6) Fistula of stomach and duodenum
(K31.6)Gastrocolic fistula
(K31.6)Gastrojejunocolic fistula – after aBillroth II a fistula forms between the transverse colon and the upper jejunum (which, post Billroth II, is attached to the remainder of the stomach). Fecal matter passes improperly from the colon to the stomach and causeshalitosis.
- Enterocutaneous fistula: between the intestine and the skin surface, namely from theduodenum or thejejunum or theileum. This definition excludes the fistulas arising from thecolon or theappendix.
- Gastric fistula: from the stomach to the skin surface
(K38.3)Fistula of appendix
(K60) Anal and rectal fissures and fistulas
- (K60.3)Anal fistula
- (K60.5)Anorectal fistula (fecal fistula, fistula-in-ano): connecting therectum or otheranorectal area to theskin surface. This results in abnormal discharge offeces through an opening other than theanus.
(K63.2) Fistula of intestine
- Enteroenteral fistula: between two parts of the intestine
(K82.3) Fistula ofgallbladder
(K83.3) Fistula ofbile duct
- Biliary fistula: connecting the bile ducts to the skin surface, often caused by gallbladder surgery
- Pancreatic fistula: between thepancreas and the exterior via theabdominal wall

M: Diseases of the musculoskeletal system and connective tissue

(M25.1) Fistula ofjoint

N: Diseases of the urogenital system

(N32.1)Vesicointestinal fistula
(N36.0)Urethral fistula
- Innora:between theprostatic utricle and the outside of the body
(N64.0)Fistula of nipple
(N82)Fistulae involving female genital tract /Obstetric fistula
- (N82.0)Vesicovaginal fistula: between thebladder and thevagina
- (N82.1) Otherfemale urinary-genital tract fistulae
  - Cervical fistula: abnormal opening in thecervix
- (N82.2)Fistula of vagina to small intestine
  - Enterovaginal fistula: between theintestine and the vagina
- (N82.3)Fistula of vagina to large intestine
  - Rectovaginal: between therectum and the vagina
- (N82.4) Otherfemale intestinal-genital tract fistulae
- (N82.5)Female genital tract-skin fistulae
- (N82.8) Otherfemale genital tract fistulae
- (N82.9)Female genital tract fistula, unspecified

Q: Congenital malformations, deformations and chromosomal abnormalities

(Q18.0)Sinus, fistula and cyst ofbranchial cleft
- Congenital preauricular fistula: A small pit in front of theear. Also known as an ear pit orpreauricular sinus.
(Q26.6)Portal vein-hepatic artery fistula
(Q38.0) Congenital fistula of lip
(Q38.4) Congenital fistula ofsalivary gland
(Q42.0) Congenital absence,atresia andstenosis ofrectum with fistula
(Q42.2) Congenital absence,atresia andstenosis ofanus with fistula
(Q43.6) Congenital fistula ofrectum andanus
(Q51.7) Congenital fistulae betweenuterus anddigestive andurinary tracts
(Q52.2) Congenitalrectovaginal fistula

T: External causes

(T14.5)Traumatic arteriovenous fistula
(T81.8)Persistent postoperative fistula

Causes

Disease: Infections including ananorectal abscess and inflammatory diseases includingCrohn's disease andulcerative colitis can result in fistulas.^[10]^[11] Fistulas to the anus may occur inhidradenitis suppurativa.^[12] In women, fistulas can also occur following pelvic infection and inflammation.^[10]

Probed surgically excised gastrocutaneous fistula tract, that resulted from a previous gastrostomy tube.

Surgical and medical treatment: Complications fromgallbladder surgery can lead to biliary fistulas.^[13] As well as being congenital or resulting from trauma,arteriovenous fistulas are created purposefully forhemodialysis.^[6] Radiation therapy to the pelvis can lead to vesicovaginal fistulas.^[10] Persistent gastrocutaneous fistulas can develop aftergastrostomy.^[14]
Trauma: Prolonged childbirth can lead to fistulas in women, in whom abnormal connections may occur between the bladder and vagina, or the rectum and vagina.^[10] Anobstetric fistula develops when blood supply to the tissues of the vagina and the bladder (and/or rectum) is cut off during prolonged obstructed labor. The tissues die and a hole forms through which urine and/or feces pass uncontrollably.Vesicovaginal andrectovaginal fistulas may also be caused by rape, in particular gang rape, and rape with foreign objects, as evidenced by the abnormally high number of women in conflict areas who have developed fistulae.^[15]^[16] In 2003, thousands of women in easternCongo presented themselves for treatment of traumatic fistulas caused by systematic, violent gang rape, often also with sharp objects that occurred during the country's five years of war. So many cases have been reported that the destruction of the vagina is considered a war injury and recorded by doctors as a crime of combat.^[17] Head trauma can lead toperilymph fistulas, whereas trauma to other parts of the body can cause arteriovenous fistulas.^[18]

Treatment

Treatment for fistula varies depending on the cause and extent of the fistula, but often involves surgical intervention combined withantibiotic therapy. In some cases the fistula is temporarily covered, using a fibrin glue or plug. Catheters may be required to drain a fistula.^[3]

Surgery is often required to assure adequate drainage of the fistula (so thatpus may escape without forming anabscess). Various surgical procedures are used, most commonlyfistulotomy, placement of aseton (a cord that is passed through the path of the fistula to keep it open for draining), or an endorectal flap procedure (where healthy tissue is pulled over the internal side of the fistula to keep feces or other material from reinfecting the channel).^[19]

Management involves treating any underlying causative condition. For example, surgical treatment of fistulae inCrohn's disease can be effective, but if the Crohn's disease itself is not treated, the rate of recurrence of the fistula is very high (well above 50%).

Therapeutic use

In people withkidney failure, requiring dialysis, acimino fistula is often deliberately created in the arm by means of a short day surgery in order to permit easier withdrawal of blood forhemodialysis.^{[citation needed]}

As a radical treatment forportal hypertension, surgical creation of a portacaval fistula produces an anastomosis between thehepatic portal vein and theinferior vena cava across the omental foramen (of Winslow). This spares the portal venous system from high pressure which can cause esophageal varices,caput medusae, and hemorrhoids.^{[citation needed]}

Epidemiology

Globally, every year between 50,000 and 100,000 women are affected by fistula relating to childbirth.^[7]

Botany

Inbotany, the term is most common in its adjectival forms, where it is used inbinomial names to refer to species that are distinguished by hollow or tubular structures.Monarda fistulosa, for example, has tubular flowers;^[8]Eutrochium fistulosum has a tubular stem;Allium fistulosum has hollow or tubular leaves, andAcacia seyal subsp.fistula is the subspecies with hollow spines.^{[citation needed]}

Society and culture