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Abstract
Gastrointestinal (GI) fistulae are defined as an abnormal communication between the gastrointestinal tract and the skin and/or the epithelial surface of an adjacent viscus. GI fistulae are the most feared complications caused by a variety of medical conditions including abdominal surgery, inflammatory bowel disease, abscess, radiation, or trauma. The management of GI fistulae is complex and requires a detailed, stepwise approach to achieve successful closure. The ultimate goal of management is to re-establish the continuity of the GI tract, while limiting the morbidity and mortality. Interventional radiology can play an important role in the diagnosis and treatment of GI fistulae. In this article, we review the clinical and radiologic features and interventional treatment of GI fistulae.
References
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Fig. 1.
An external and low-output fistula after low anterior resection for rectal cancer. A. Axial CT image shows a colo-cutaneous fistula in the left lower abdomen (arrows). B. Fistulogram using iodinated water soluble contrast medium shows direct communication into the sigmoid colon (arrows). C. Two-month follow-up CT after external drainage shows disappearance of the fistulous tract (arrows). CT = computed tomography
Fig. 2.
An internal, ileo-colic fistula in Crohn's disease. A–C. Three dimensional reconstruction (A, B) and axial computed tomography (C) images after oral contrast ingestion show an ileo-colic fistula (arrows). D. Fistula tract between the ileum and the transverse colon is seen in a small bowel study (arrow).
Fig. 3.
External and high-output fistula (duodeno-cutaneous fistula) after surgical repair of traumatic duodenal perforation. A-C. In the initial (A) and follow-up contrast studies (B, C), an abscess cavity and a fistula tract (arrows) between the duodenum and skin are seen. D. Follow-up contrast study shows a completely closed fistula tract (arrow) after percutaneous radiologic drainage.
Fig. 4.
An internal, pancreatico-jejunal fistula in a malignant intramural papillary mucinous tumor. A. Initial, abdominal US image shows diffuse pancreatic duct dilatation. B, C. Axial (B) and three dimensional reconstruction CT (C) images taken three days after US show a pancreatico-jejunal fistula (arrows). Pancreatic duct dilatation is somewhat improved due to the fistula. CT = computed tomography, US = ultrasonography
Fig. 5.
External and high-output fistula after subtotal gastrectomy and gastroduodenostomy. A. Axial computed tomography image after the operation shows an air-containing abscess (arrows) around the operation site. B. After percutaneous drainage of the abscess, a fistula tract to the anastomotic site is noted (arrow). C. Upper gastrointestinal study performed 2 weeks after percutaneous drainage shows disappearance of the fistula tract.
Fig. 6.
Transgluteal approach in the prone position for a presacral, pelvic abscess after proctocolectomy for rectal cancer. A. Axial computed tomography image shows complicated fluid collection in the presacral space (arrows). B. Percutaneous catheter drainage was performed via the left transgluteal route in the prone position.
Fig. 7.
Transvaginal approach for a deep-seated pelvic abscess after hysterectomy. A, B. Axial computed tomography image shows an irregular-shaped abscess cavity in the pelvic cavity and a fistula tract between the sigmoid colon and the abscess cavity (arrow). C. Transvaginal catheter drainage was performed under fluoroscopic guidance.
Fig. 8.
Complex external and internal fistulae in a patient with necrotizing pancreatitis. A. Axial computed tomography image shows necrotizing pancreatitis and irregular fluid collection around the peripancreatic space (arrows). B. Contrast study via a drainage catheter shows complex fistulae among the abscess cavity, stomach, duodenum, and ascending colon. C. Upper gastrointestinal study after radiologic feeding jejunal tube insertion. The fistulae were closed 8 weeks after drainage tube and feeding jejunal tube insertion.
Fig. 9.
External (duodeno-cutaneous) fistula after subtotal gastrectomy and gastroduodenostomy for stomach cancer. A. Endoscopic image shows an internal fistula opening in the second portion of the duodenum (arrow). B. Sinogram of the fistula demonstrates a fistula tract to the second portion of the duodenum (arrow). C. Histoacryl glue (N-butyl-2-cyanoacrylate)-Lipiodol mixture (1:1) injection was performed for blockage of the fistula tract 8 weeks after conservative management. D. Follow-up computed tomography image shows blockage of the fistula tract with glue (arrow).
Fig. 10.
Histoacryl glue (NBCA) injection for a long-standing periappendiceal abscess –ascending colon fistula. A. Contrast study through a drainage catheter shows a fistula tract between the abscess cavity and the ascending colon (arrow). B. Histoacryl glue (NBCA)-Lipiodol mixture (1:1) injection was performed for blockage of the fistula tract 6 weeks after conservative management (arrow). C, D. Follow-up axial (C) and coronal (D) computed tomography images shows blockage of the previous fistula tract (arrows). NBCA = N-butyl-2-cyanoacrylate
Fig. 11.
Histoacryl glue (NBCA) injection and rubber patch application for a longstanding recto-vaginal fistula due to radiation therapy. A. Colon study shows a recto-vaginal fistula (arrow). B, C. Rubber patch application (B) and histoacryl glue (NBCA)-Lipiodol mixture (1:1) injection (C) was performed (arrows). After the procedure, fecal discharge from the vagina was markedly decreased. NBCA = N-butyl-2-cyanoacrylate
Fig. 12.
Covered metal stent placement for blockage of a sigmoid colo-vesical fistula in a patient with sigmoid colon cancer. A. Abdomen CT images show sigmoid colon cancer with a fistula tract between the sigmoid colon and the urinary bladder (arrow). B. Free air in the urinary bladder is seen due to the fistula (arrowhead). C. Covered metal stent placement (Hanaro, MI Tech, Seoul, Korea; 22 mm in diameter and 120 mm in length) was performed and the fistula tract was closed successfully. D. Follow-up coronal CT image 2 months after stent placement shows disappearance of the previous fistula tract (arrow). CT = computed tomography
Table 1.
Classification of Gastrointestinal Fistulae
Table 2.
Etiologic Classification of Gastrointestinal Fistulae
Table 3.
Factors Affecting Spontaneous Closure of Gastrointestinal Fistulae
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