Chronic enterocutaneous fistula: management in the community setting

Clinical considerations

In 1988, Tonn identified three key nursing objectives for providing effective fistula care:

Some 32 years later, these objectives remain pivotal to the management of fistulas. In 2016, the Association of Stoma Care Nurses published its national guidelines, which included a section on fistula management. A focal point is that patients with a faecal fistula should be seen and assessed by the stoma care nurse and an individualised care plan formulated.

The acute medical management of these patients focuses on the control of sepsis, maintenance of adequate fluid and electrolyte balance, provision of complication-free nutritional support and skin care (Kaushal and Carlson, 2004).

Key aspects of chronic enterocutaneous fistula management include promoting ‘normality’ for the patient, encouraging mobility, and enabling patients to care for their fistulas independently, if possible (Burch, 2011).

Metcalf (2019) described the psychological support required by patients with an enterocutaneous fistula, who often experience anxiety, feelings of loss, depression and anger, as well as loss of self-esteem, particularly if the fistula was secondary to a postoperative complication.

Nutritional considerations

Although oral intake of food may be limited when managing an enterocutaneous fistula during its acute phase, a different management approach needs to be adopted when supporting these patients in the long term.

Willcutts et al (2005) commented that a fistula will increase morbidity and predispose the patient to malnutrition, as it will reduce their desire to eat and, if located in the proximal gut, its drainage will increase the loss of nutrients. Treatment regimens vary, depending on individual needs, and can result in the use of total parenteral nutrition and a reduced oral intake. Metcalf (2019) highlighted that eating is psychologically beneficial, and, where an oral intake is possible, efforts should focus on implementing a high-calorie, low-fibre diet to slow motility through the small bowel, increasing nutrient absorption.

Moisture-associated skin damage

Faecal effluent is a source of chemical irritation to the skin. However, with enterocutaneous fistulas, it is the pH value of the content of fistula effluent, rather than the volume, that will determine its effect on the skin, as small bowel secretions contain active digestive enzymes, such as trypsin, lipase and peptidase, that will erode the skin (Curtis and Judson, 2014). Any increase in the skin pH will enhance the proteolytic activity of these digestive enzymes, which will in turn impair the skin's barrier function (Beeckman et al, 2015). Exposure of the epidermis to fluid, digestive enzymes and pH extremes will thus lead to maceration, denudation, erythema and erosion.

In the UK, many types of containment devices are used for fistula management: fistula pouches, wound managers and, sometimes, drainable stoma pouches. Product selection is often governed by the size of the fistula and the volume of fluid produced. A wound manager is likely to be the first choice for a fistula in an open wound with a large surface area that is producing a high fluid output. At the opposite end of the spectrum, a fistula pouch, which has a narrower rectangular adhesive baseplate and a much smaller fluid containment pouch, is selected for smaller fistulas. Containment devices use hydrocolloid adhesives to adhere to the surrounding skin.

In some circumstances, additional stoma accessories, such as washers and stoma paste, may be of benefit: these can be used to create a flatter surface for the adhesive to adhere to, which will increase wear time by reducing leakage.

Case study

Through case studies, Curtis and Judson (2014) highlighted the complexities involved in protecting the peri-fistula skin and the unique challenges faced by nurses and patients, with successful containment of effluent sometimes requiring ingenuity, creativity and a trial-and-error approach.

This article describes a complex case study involving a patient with an enterocutaneous fistula who was cared for in the community. The primary goal was to support the patient and promote self-care and independence, rather than aiming for wound healing or resolution of the fistula.

Mrs B, who was in her 80s, lived independently in her own home. Her main comorbidities were diverticulitis and fibromyalgia, which did not affect the dexterity of her hands.

Two years previously, she had elective surgery to resolve a strangulated bowel. Following her discharge from hospital, the community nursing service provided her postoperative wound care. Unfortunately, a spontaneous enterocutaneous fistula developed and Mrs B returned to the surgical team where the decision was taken to attempt self-closure of the fistula. Unfortunately, this was not successful.

Following surgery, Mrs B received training on how to self-manage her fistula and was discharged home. She continued to manage the fistula independently over a 2-year period until she presented at her GP practice complaining of a general malaise. Mrs B had initially used a fistula pouch, but was currently using a wound manager.

Mrs B's GP diagnosed an urinary tract infection and prescribed oral antibiotics. She was referred to the community nursing service, who discovered that she had a category 3 sacral pressure ulcer and was experiencing complex issues related to the self-care of her fistula.

Mrs B was extremely embarrassed about the fistula, leakage and malodour. Her previous coping mechanisms were challenged by her ‘malaise’ (the UTI and leakage from fistula), which had impacted her kidney function and, due to the associated reduction in mobility, maceration and general ill health, had contributed to the pressure ulceration.

The community nurses also observed evidence of peri-fistula moisture-associated skin damage (MASD). They likened the appearance of the peri-fistula skin to that of a burn, noting that it was causing Mrs B severe pain (self-reported as 5–6 on a 10-point visual analogue scale (VAS)).

Mrs B was immediately referred to the tissue viability service, as an understanding of wound management is vital for enhancing patient comfort and fistula healing (Hoedema and Suryadevara, 2010). On 3 April 2019, the tissue viability nurse (TVN) visited the patient at home, where she undertook a patient assessment and documented the skin damage (Table 1). A multidisciplinary treatment plan was devised, which focused on nutrition, pain relief and pressure-redistribution, and incorporated strategies to contain the fistula effluent and improve the skin integrity. A total care package was developed, with home delivery of meals, a pharmacological review and regular visits (every 48 hours) by the community nursing staff to assess Mrs B's progress and offer her psychological support, with a view to reinforcing her own coping mechanisms. The psychological support was particularly important as Mrs B had resigned herself to ‘accept that this is what I've got to get on with’: her aim was to self-care and achieve independence.

The primary objective of fistula management was to identify the most suitable drainage bag for this patient's needs, to minimise leakage and improve the skin integrity. However, not only is it often difficult to establish which fistula drainage bag is most effective at providing a leak-free seal, but also these devices are often not included in community formularies.

Initially, a simple stoma pouch was used, along with Octenilin Wound Irrigation Solution (Schulke) to cleanse the peri-fistula skin, and LBF Sterile Barrier Film Spray and Appeel Sterile Medical Adhesive Remover (both CliniMed), to protect the skin from the adhesive stoma pouch. LBF is an alcohol-free, sting-free, sterile skin barrier that softens and soothes (Slater, 2011). It dries within seconds of application, creating a breathable and transparent film on the skin. A recent Journal of Wound Care (JWC) international consensus document on the prevention of medical adhesive-related skin injury (MARSI) recommended that use of sterile skin barriers should be considered for patients at high risk of infection, such as Mrs B (Fumarola et al, 2020).

At the next follow-up visit 5 days later (8 April), there was a marked improvement in Mrs B's peri-fistula skin, and her self-reported pain score had reduced to 2–3/10 (Table 1).

According to Aminu et al (2000), Manuka honey is a reliable alternative to conventional dressings for managing excoriated skin around stoma sites, as it facilitates epithelialisation. It was therefore decided to prescribe a drainable pouch with an adhesive flange containing Manuka honey (Aura, CliniMed). Due to an unintentional delay in the supply of the pouch, Mrs B was unable to collect this prescription and so had to use a wound manager instead. Leakage of fistula output from the alternative device's flange resulted in skin irritation (Table 1).

The condition of the peri-fistula skin improved when Mrs B was able to access the drainable pouch and Manuka honey adhesive flange. A home-delivery service was arranged for Mrs B, to ensure a regular supply, as a subsequent, albeit brief (2-day), shortage resulted in further skin irritation (Table 1), which resolved when use of the pouch and Manuka honey adhesive flange resumed. The same skin cleansing and protectant regimen continued to be used. Mrs B confirmed that the combination of a drainable pouch and a Manuka honey adhesive flange was her preferred choice of collection device.

As the condition of Mrs B's peri-fistula skin improved, with no leakage or malodour, no further community nurse or tissue viability visits were required. Mrs B continued to use the skin-care and treatment regimen described above. In this way, she achieved her goal of being able to self-care and attain independence.

For Mrs B, maintaining the condition of her peri-fistula skin will remain a lifelong challenge, but she is now much better equipped to identify when it is getting sore, what she can do about this and when to ask the community nursing service for help. Slater (2011) summarises the need for psychological care during nursing interventions; the type of fistula, the patient's ability and willingness to care for the drainage bag and their psychological state will determine the level and type of support and nursing input required.

Conclusion

The main principles of enterocutaneous fistula nursing management remain constant throughout the provision of care, with a focus on maintaining skin integrity, accurate recording of intake and output, ensuring adequate nutrition and providing psychological support (Thompson and Epanomeritakis, 2008).

This case study provides a clinical example confirming the statement by Reed et al (2006) that enterocutaneous fistulas can be severely debilitating for patients and the drainage painfully damaging to the surrounding skin. Careful skin management is thus a primary goal of non-surgical fistula care. According to Willcutts et al (2005), an effective fistula skin management plan should strive to achieve skin protection, patient comfort, odour control, patient mobility, drainage containment and cost control.

The Association of Stoma Care Nurses (2016)Stoma Care National Clinical Guidelines recommend that the patient and stoma care nurse should agree a plan to manage the fistula, contain the effluent, prevent skin breakdown and provide comfort. In this case, as in some other parts of the country, patients with an enterocutaneous fistula are seen by a TVN rather than a stoma care nurse. Here, the TVN and the patient devised the treatment plan. The combination of a drainage pouch and Manuka honey adhesive flange was found to be the most effective device: it reduced leakage, protected the surrounding skin from irritation and enabled the patient to self-manage. The wear time of the Manuka honey adhesive flange enabled alternate-day pouch changes, which were undertaken by Mrs B, who stated that this was her preferred product. The long-term management plan needed to provide an acceptable routine for Mrs B, as the aetiology of her fistula meant it was not possible to completely stop the leakage.

The important contribution of the multidisciplinary approach described here supports the comment by Slater (2011) that nurses have a multifactorial role to play in the care of patients with an enterocutaneous fistula. Aside from the general care of the peri-fistula skin, support and counselling play a pivotal role in rehabilitation, which involves helping patients with an enterocutaneous fistula to adjust to life in the community.

Key Points

CPD reflective questions