Management of Colocutaneous Fistula

Etiology and Presentation

Colocutaneous fistulas are uncommon but significant complications that may occur when the colon is inadvertently punctured during gastrostomy placement or when a tube erodes into the adjacent colon 1
Patients typically present with stool leaking around the gastrostomy tube 1
Fecal discharge from a wound or cutaneous opening is a common presentation 2, 3
A common scenario is when a replacement gastrostomy tube is advanced through a previously created gastrocolocutaneous fistula into the colon rather than through the colon into the stomach 1

Radiographic identification is essential - a feeding tube misplaced into the colon can be visualized with contrast studies 1
MRI is the preferred diagnostic tool for enteric fistulas, offering the highest sensitivity and specificity for defining the anatomy of the fistulous tract 4
Assessment should include the location of the fistula 1
Assessment should include the volume of output (low <200 ml/day, moderate 200-500 ml/day, high >500 ml/day) 4
Patient's nutritional status and hydration should be assessed 5

Conservative management involves removing the tube and allowing the fistula to close spontaneously 1, 2, 3
Fluid resuscitation and electrolyte rebalancing are essential, especially for high-output fistulae 4
Nutritional support through enteral or parenteral nutrition depending on fistula location and output is recommended 5
Skin protection to prevent excoriation from fistula output is necessary 4, 5

Surgery is required when signs of peritonitis develop 1, 2, 3
Surgery is required when the fistula fails to heal with conservative management 1, 2, 3
Surgical timing is critical, and the patient should be optimized nutritionally preoperatively 5

High-output fistulas require restriction of hypotonic/hypertonic fluids to <1000 ml daily 5
Inflammatory bowel disease-related fistulas may benefit from anti-TNF therapy 4
Approximately one-third of patients achieve fistula healing with anti-TNF therapy 4

The safe-track technique should be used during gastrostomy placement 1
The head of the bed should be elevated with adequate gastric insufflation during placement to displace the colon inferiorly 1
Excessive lateral traction on gastrostomy tubes should be avoided 2

Initiating anti-TNF therapy before adequate drainage of abscesses can worsen sepsis 4
Immediate surgical resection without adequate preparation leads to poorer outcomes 4, 5
Neglecting skin care can lead to significant skin breakdown and additional morbidity 4
Failure to address associated complications will reduce success rates of both medical and surgical interventions 4