Medical Management of the High-Output Enterostomy and Enterocutaneous Fistula

  • Neha Parekh
  • Douglas L. Seidner


Medical management of the high-output enterostomy or enterocutaneous fistula (ECF) requires an understanding of mechanisms behind the malabsorption associated with short bowel syndrome (SBS) and intestinal failure (IF). A traditional definition of SBS is <200 cm of remaining viable jejunum and ileum following surgical resection for disease, trauma, infarction, or congenital defect. A more functional definition involves consideration of the quality of the bowel in continuity and the clinical status of the patient, both of which may further interfere with absorptive capacity of the bowel. A thorough examination of remaining functional and structural anatomy can reveal potential causes of persistent malabsorption.


Small Bowel Parenteral Nutrition Short Bowel Syndrome Oral Rehydration Solution Enterocutaneous Fistula 
These keywords were added by machine and not by the authors. This process is experimental and the keywords may be updated as the learning algorithm improves.


  1. 1.
    Thompson JS. Management of the short bowel syndrome. Gastroenterol Clin North Am. 1994;23(2):403–20.PubMedGoogle Scholar
  2. 2.
    Borgstrom B, Dahlqvist A, Lundh G, Sjovall J. Studies of intestinal digestion and absorption in the human. J Clin Invest. 1957;36(10):1521–36.PubMedCrossRefGoogle Scholar
  3. 3.
    Nightingale JM, Kamm MA, van der Sijp JR, et al. Disturbed gastric emptying in the short bowel syndrome. Evidence for a ‘colonic brake’. Gut. 1993;34(9):1171–6.PubMedCrossRefGoogle Scholar
  4. 4.
    Hofmann AF, Poley JR. Role of bile acid malabsorption in pathogenesis of diarrhea and steatorrhea in patients with ileal resection. I. Response to cholestyramine or replacement of dietary long chain triglyceride by medium chain triglyceride. Gastroenterology. 1972;62(5):918–34.PubMedGoogle Scholar
  5. 5.
    Debongnie JC, Phillips SF. Capacity of the human colon to absorb fluid. Gastroenterology. 1978;74(4):698–703.PubMedGoogle Scholar
  6. 6.
    Ziegler TR, Fernandez-Estivariz C, Gu LH, et al. Distribution of the H+/peptide transporter PepT1 in human intestine: up-regulated expression in the colonic mucosa of patients with short-bowel syndrome. Am J Clin Nutr. 2002;75(5):922–30.PubMedGoogle Scholar
  7. 7.
    Royall D, Wolever TM, Jeejeebhoy KN. Evidence for colonic conservation of malabsorbed carbohydrate in short bowel syndrome. Am J Gastroenterol. 1992;87(6):751–6.PubMedGoogle Scholar
  8. 8.
    Parekh N, Seidner D, Steiger E. Managing short bowel syndrome: making the most of what the patient still has. Cleve Clin J Med. 2005;72(9):833–8.PubMedCrossRefGoogle Scholar
  9. 9.
    Buchman AL, Scolapio J, Fryer J. AGA technical review on short bowel syndrome and intestinal transplantation. Gastroenterology. 2003;124(4):1111–34.PubMedCrossRefGoogle Scholar
  10. 10.
    Nordgaard I, Hansen BS, Mortensen PB. Importance of colonic support for energy absorption as small-bowel failure proceeds. Am J Clin Nutr. 1996;64(2):222–31.PubMedGoogle Scholar
  11. 11.
    Jeppesen PB, Mortensen PB. Colonic digestion and absorption of energy from carbohydrates and medium-chain fat in small bowel failure. JPEN J Parenter Enteral Nutr. 1999;23 Suppl 5:S101–5.PubMedCrossRefGoogle Scholar
  12. 12.
    Wilmore DW. Indications for specific therapy in the rehabilitation of patients with the short-bowel syndrome. Best Pract Res Clin Gastroenterol. 2003;17(6):895–906.PubMedCrossRefGoogle Scholar
  13. 13.
    Jeppesen PB, Mortensen PB. Significance of a preserved colon for parenteral energy requirements in patients receiving home parenteral nutrition. Scand J Gastroenterol. 1998;33(11):1175–9.PubMedCrossRefGoogle Scholar
  14. 14.
    Nightingale JM, Bartram CI, Lennard-Jones JE. Length of residual small bowel after partial resection: correlation between radiographic and surgical measurements. Gastrointest Radiol. 1991 Fall;16(4):305–6.Google Scholar
  15. 15.
    Crenn P, Coudray-Lucas C, Thuillier F, Cynober L, Messing B. Postabsorptive plasma citrulline concentration is a marker of absorptive enterocyte mass and intestinal failure in humans. Gastroenterology. 2000;119(6):1496–505.PubMedCrossRefGoogle Scholar
  16. 16.
    Jianfeng G, Weiming Z, Ning L, et al. Serum citrulline is a simple quantitative marker for small intestinal enterocytes mass and absorption function in short bowel patients. J Surg Res. 2005;127(2):177–82.PubMedCrossRefGoogle Scholar
  17. 17.
    Rhoads JM, Plunkett E, Galanko J, et al. Serum citrulline levels correlate with enteral tolerance and bowel length in infants with short bowel syndrome. J Pediatr. 2005;146(4):542–7.PubMedCrossRefGoogle Scholar
  18. 18.
    Parekh NR, Natowicz M, Lopez R, Seidner DL, Su L, Steiger E. Plasma citrulline is a marker of home parenteral nutrition dependence in patients with short bowel syndrome. Clin Nutr Suppl. 2008;3(1):71–2.CrossRefGoogle Scholar
  19. 19.
    Kim KA, Wry P, Hughes Jr E, Butcher J, Barbot D. Clostridium difficile small-bowel enteritis after total proctocolectomy: a rare but fatal, easily missed diagnosis. Report of a case. Dis Colon Rectum. 2007;50(6):920–3.PubMedCrossRefGoogle Scholar
  20. 20.
    Jeppesen PB, Mortensen PB. Intestinal failure defined by measurements of intestinal energy and wet weight absorption. Gut. 2000;46(5):701–6.PubMedCrossRefGoogle Scholar
  21. 21.
    Fazio VW, Coutsoftides T, Steiger E. Factors influencing the outcome of treatment of small bowel cutaneous fistula. World J Surg. 1983;7(4):481–8.PubMedCrossRefGoogle Scholar
  22. 22.
    Chapman R, Foran R, Dunphy JE. Management of intestinal fistulas. Am J Surg. 1964;108:157–64.PubMedCrossRefGoogle Scholar
  23. 23.
    Kuvshinoff BW, Brodish RJ, McFadden DW, Fischer JE. Serum transferrin as a prognostic indicator of spontaneous closure and mortality in gastrointestinal cutaneous fistulas. Ann Surg. 1993;217(6):615–22; discussion 22–3.PubMedCrossRefGoogle Scholar
  24. 24.
    Meguid MM, Campos AC. Nutritional management of patients with gastrointestinal fistulas. Surg Clin North Am. 1996;76(5):1035–80.PubMedCrossRefGoogle Scholar
  25. 25.
    Dudrick SJ, Maharaj AR, McKelvey AA. Artificial nutritional support in patients with gastrointestinal fistulas. World J Surg. 1999;23(6):570–6.PubMedCrossRefGoogle Scholar
  26. 26.
    Makhdoom ZA, Komar MJ, Still CD. Nutrition and enterocutaneous fistulas. J Clin Gastroenterol. 2000;31(3):195–204.PubMedCrossRefGoogle Scholar
  27. 27.
    Cheatham ML, Safcsak K, Brzezinski SJ, Lube MW. Nitrogen balance, protein loss, and the open abdomen. Crit Care Med. 2007;35(1):127–31.PubMedCrossRefGoogle Scholar
  28. 28.
    Staun M, Pironi L, Bozzetti F, et al. ESPEN guidelines on parenteral nutrition: home parenteral nutrition (HPN) in adult patients. Clin Nutr. 2009;28(4):467–79.PubMedCrossRefGoogle Scholar
  29. 29.
    Wolman SL, Anderson GH, Marliss EB, Jeejeebhoy KN. Zinc in total parenteral nutrition: requirements and metabolic effects. Gastroenterology. 1979;76(3):458–67.PubMedGoogle Scholar
  30. 30.
    Matarese LE, Steiger E. Dietary and medical management of short bowel syndrome in adult patients. J Clin Gastroenterol. 2006;40 Suppl 2:S85–93.PubMedCrossRefGoogle Scholar
  31. 31.
    Buchman AL. Etiology and initial management of short bowel syndrome. Gastroenterology. 2006;130(2 Suppl 1):S5–15.PubMedCrossRefGoogle Scholar
  32. 32.
    Martinez-Riquelme A, Rawlings J, Morley S, Kendall J, Hosking D, Allison S. Self-administered subcutaneous fluid infusion at home in the management of fluid depletion and hypomagnesaemia in gastro-intestinal disease. Clin Nutr. 2005;24(1):158–63.PubMedCrossRefGoogle Scholar
  33. 33.
    Messing B, Crenn P, Beau P, Boutron-Ruault MC, Rambaud JC, Matuchansky C. Long-term survival and parenteral nutrition dependence in adult patients with the short bowel syndrome. Gastroenterology. 1999;117(5):1043–50.PubMedCrossRefGoogle Scholar
  34. 34.
    Lennard-Jones JE. Oral rehydration solutions in short bowel syndrome. Clin Ther. 1990;12(Suppl A):129–37; discussion 38.PubMedGoogle Scholar
  35. 35.
    Byrne TA, Veglia L, Camelio M, et al. Clinical observations: beyond the prescription: optimizing the diet of patients with short bowel syndrome. Nutr Clin Pract. 2000;15:306–11.CrossRefGoogle Scholar
  36. 36.
    Nightingale J. Gastrostomy placement in patients with Crohn’s disease. Eur J Gastroenterol Hepatol. 2000;12(10):1073–5.PubMedCrossRefGoogle Scholar
  37. 37.
    Joly F, Dray X, Corcos O, Barbot L, Kapel N, Messing B. Tube feeding improves intestinal absorption in short bowel syndrome patients. Gastroenterology. 2009;136(3):824–31.PubMedCrossRefGoogle Scholar
  38. 38.
    Kollman KA, Lien EL, Vanderhoof JA. Dietary lipids influence intestinal adaptation after massive bowel resection. J Pediatr Gastroenterol Nutr. 1999;28(1):41–5.PubMedCrossRefGoogle Scholar
  39. 39.
    Parekh NR, Seidner DL. Advances in enteral feeding of the intestinal failure patient. Support Line. 2006;28:18–24.Google Scholar
  40. 40.
    Welters CF, Dejong CH, Deutz NE, Heineman E. Intestinal adaptation in short bowel syndrome. ANZ J Surg. 2002;72(3):229–36.PubMedCrossRefGoogle Scholar
  41. 41.
    Nauth J, Chang CW, Mobarhan S, Sparks S, Borton M, Svoboda S. A therapeutic approach to wean total parenteral nutrition in the management of short bowel syndrome: three cases using nocturnal enteral rehydration. Nutr Rev. 2004;62(5):221–31.PubMedCrossRefGoogle Scholar
  42. 42.
    Jeejeebhoy KN. Short bowel syndrome: a nutritional and medical approach. CMAJ. 2002;166(10):1297–302.PubMedGoogle Scholar
  43. 43.
    American Gastroenterological Association medical position statement. Short bowel syndrome and intestinal transplantation. Gastroenterology. 2003;124(4):1105–10.CrossRefGoogle Scholar
  44. 44.
    Seidner DL. Short bowel syndrome: etiology, pathophysiology and management. Pract Gastroenterol. 2001;25:63–72.Google Scholar
  45. 45.
    Nehra V, Camilleri M, Burton D, Oenning L, Kelly DG. An open trial of octreotide long-acting release in the management of short bowel syndrome. Am J Gastroenterol. 2001;96(5):1494–8.PubMedCrossRefGoogle Scholar
  46. 46.
    McDoniel K, Taylor B, Huey W, et al. Use of clonidine to decrease intestinal fluid losses in patients with high-output short-bowel syndrome. JPEN J Parenter Enteral Nutr. 2004;28(4):265–8.PubMedCrossRefGoogle Scholar
  47. 47.
    Yang H, Teitelbaum DH. Novel agents in the treatment of intestinal failure: humoral factors. Gastroenterology. 2006;130(2 Suppl 1):S117–21.PubMedCrossRefGoogle Scholar
  48. 48.
    Byrne TA, Wilmore DW, Iyer K, et al. Growth hormone, ­glutamine, and an optimal diet reduces parenteral nutrition in patients with short bowel syndrome: a prospective, randomized, placebo-­controlled, double-blind clinical trial. Ann Surg. 2005;242(5):655–61.PubMedCrossRefGoogle Scholar
  49. 49.
    Scolapio JS. Short bowel syndrome: recent clinical outcomes with growth hormone. Gastroenterology. 2006;130(2 Suppl 1):S122–6.PubMedCrossRefGoogle Scholar
  50. 50.
    Jeppesen PB, Sanguinetti EL, Buchman A, et al. Teduglutide (ALX-0600), a dipeptidyl peptidase IV resistant glucagon-like peptide 2 analogue, improves intestinal function in short bowel syndrome patients. Gut. 2005;54(9):1224–31.PubMedCrossRefGoogle Scholar
  51. 51.
    Mcintyre PB, Ritchie JK, Hawley PR, Bartram CI, Lennard-Jones JE. Management of enterocutaneous fistulas: a review of 132 cases. Br J Surg. 1984;71:293–6.PubMedCrossRefGoogle Scholar
  52. 52.
    Rose D, Yarborough MF, Canizaro PC, Lowry SF. One hundred and fourteen fistulas of the gastrointestinal tract treated with total parenteral nutrition. Surg Gynecol Obstet. 1986;163(4):345–50.PubMedGoogle Scholar
  53. 53.
    Visschers RG, Olde Damink SW, Winkens B, Soeters PB, van Gemert WG. Treatment strategies in 135 consecutive patients with enterocutaneous fistulas. World J Surg. 2008;32(3):445–53.PubMedCrossRefGoogle Scholar
  54. 54.
    Levy E, Frileux P, Cugnenc PH, Honiger J, Ollivier JM, Parc R. High-output external fistulae of the small bowel: management with continuous enteral nutrition. Br J Surg. 1989;76(7):676–9.PubMedCrossRefGoogle Scholar
  55. 55.
    Ham M, Horton K, Kaunitz J. Fistuloclysis: case report and literature review. Nutr Clin Pract. 2007;22(5):553–7.PubMedCrossRefGoogle Scholar
  56. 56.
    Teubner A, Morrison K, Ravishankar HR, Anderson ID, Scott NA, Carlson GL. Fistuloclysis can successfully replace parenteral feeding in the nutritional support of patients with enterocutaneous fistula. Br J Surg. 2004;91(5):625–31.PubMedCrossRefGoogle Scholar
  57. 57.
    Hyon SH, Martinez-Garbino JA, Benati ML, Lopez-Avellaneda ME, Brozzi NA, Argibay PF. Management of a high-output postoperative enterocutaneous fistula with a vacuum sealing method and continuous enteral nutrition. ASAIO J. 2000;46(4):511–4.PubMedCrossRefGoogle Scholar
  58. 58.
    Goverman J, Yelon JA, Platz JJ, Singson RC, Turcinovic M. The “Fistula VAC,” a technique for management of enterocutaneous fistulae arising within the open abdomen: report of 5 cases. J Trauma. 2006;60(2):428–31; discussion 31.PubMedCrossRefGoogle Scholar
  59. 59.
    Torres AJ, Landa JI, Moreno-Azcoita M, et al. Somatostatin in the management of gastrointestinal fistulas. A multicenter trial. Arch Surg. 1992;127(1):97–9; discussion 100.PubMedCrossRefGoogle Scholar
  60. 60.
    Spiliotis J, Briand D, Gouttebel MC, et al. Treatment of fistulas of the gastrointestinal tract with total parenteral nutrition and octreotide in patients with carcinoma. Surg Gynecol Obstet. 1993;176(6):575–80.PubMedGoogle Scholar
  61. 61.
    Alivizatos V, Felekis D, Zorbalas A. Evaluation of the effectiveness of octreotide in the conservative treatment of postoperative enterocutaneous fistulas. Hepatogastroenterology. 2002;49(46):1010–2.PubMedGoogle Scholar
  62. 62.
    Sancho JJ, di Costanzo J, Nubiola P, et al. Randomized double-blind placebo-controlled trial of early octreotide in patients with postoperative enterocutaneous fistula. Br J Surg. 1995;82(5):638–41.PubMedCrossRefGoogle Scholar
  63. 63.
    Seidner DL, Speerhas R. Can octreotide be added to parenteral nutrition solutions? Point-counterpoint. Nutr Clin Pract. 1998;13:84–8.CrossRefGoogle Scholar
  64. 64.
    Hwang TL, Chen MF. Randomized trial of fibrin tissue glue for low output enterocutaneous fistula. Br J Surg. 1996;83(1):112.PubMedCrossRefGoogle Scholar
  65. 65.
    Huang CS, Hess DT, Lichtenstein DR. Successful endoscopic management of postoperative GI fistula with fibrin glue injection: report of two cases. Gastrointest Endosc. 2004;60(3):460–3.PubMedCrossRefGoogle Scholar

Copyright information

© Springer Science+Business Media, LLC 2012

Authors and Affiliations

  1. 1.Intestinal Rehabilitation and Transplant Nutrition, Digestive Disease InstituteCleveland Clinic FoundationClevelandUSA
  2. 2.Division of Gastroenterology, Hepatology and Nutrition, Vanderbilt Center for Human NutritionVanderbilt University Medical CenterNashvilleUSA

Personalised recommendations