duodenal fistula
Introduction
Introduction to duodenal fistula External duodenal fistula (external duodenal fistula) is a very common extraintestinal fistula and a serious complication after upper abdominal surgery and abdominal trauma. Because most of the duodenum is deep in the retroperitoneum, and there are bile ducts and pancreatic ducts, and the cause is different, it is also duodenal fistula. The expression and outcome can be very different. Extremely easy to treat, such as the duodenal stump. Some complications are numerous, the treatment is complicated, and the prognosis is extremely poor. basic knowledge Sickness ratio: 0.0012% Susceptible people: no special people Mode of infection: non-infectious Complications: malnutrition peritonitis abdominal abscess
Cause
Cause of duodenal fistula
Local lesions and trauma (30%):
There are two major causes of duodenal fistula, systemic and local. From the whole body, there are factors such as severe malnutrition, organ dysfunction, diabetes, etc., but more importantly, local lesions and trauma, such as Duodenal stump suture embedding is not satisfactory, duodenal trauma is more intense inflammation and edema, suture repair is not accurate, etc., can lead to duodenal fistula, the special anatomical location of the duodenum, Gastric juice, bile and pancreatic juice are passed through this a large number, which is also one of the reasons why the duodenal fistula is prone to occur.
Trauma (20%):
(1) Abdominal closed injury: In the closed abdominal injury, the car's steering wheel injury and high-altitude fall injury are most likely to be complicated with duodenal trauma, and because most of the duodenum is located behind the retroperitoneum, the patient suffers from bleeding, shock, etc. after injury. The cause is unstable, and it is easy to neglect the exploration of duodenal trauma. Sometimes even if duodenal trauma has been found and repairs have been performed, there is still a high incidence of duodenal fistula after surgery. rate.
(2) Abdominal knife stab wound: Because the duodenum is located in the middle and upper abdomen, it is often a good site for knife stab wounds, and it is easy to combine with other organs, such as pancreatic trauma and intestinal trauma, such as laparotomy. Inadequate detection or unsatisfactory treatment during surgery can lead to the occurrence of duodenal fistula.
Surgery (15%):
(1) Most of the stomach or total gastrectomy: patients with partial gastrectomy and total gastrectomy due to ulcer disease or gastric cancer, due to the wide range of lesions and the need for radical gastrectomy, often need duodenal stump A wide range of exfoliation is carried out around, and ischemic necrosis is easy to occur in the stump, resulting in postoperative duodenal stump paralysis. Sometimes there are different degrees of obstruction in the distal part of the duodenum. Even if the local treatment is satisfactory, it can not stop the paralysis. happened.
(2) biliary surgery: the most common biliary tract surgery for duodenal fistula is cholecystectomy and common bile duct exploration, in patients with recurrent cholecystitis, gallbladder and surrounding organs, especially the duodenum The adhesion is heavier, and the duodenum is more likely to be damaged during surgical dissection. If it is not detected in time or found to be improperly treated, it may cause duodenal fistula.
The common bile duct incision explores the combined duodenal fistula. Generally, there is a stenosis at the lower end of the common bile duct. When using different types of biliary probes for exploration, due to excessive force, the probe enters the duodenum through the lower end of the common bile duct. Can further advance the injury to the opposite side of the duodenal papilla, causing perforation of the duodenum, and even more can also hurt the transverse colon caused by the transverse colon perforation, because the probe is quickly withdrawn, this damage is often not timely It was found that eventually the duodenal fistula occurred and more serious retroperitoneal infections were found.
When the Oddi sphincter angioplasty is performed through the duodenal incision, the lower end of the common bile duct and the duodenal fistula can be caused by improper suturing due to excessive incision or improper position.
(3) Duodenal surgery: Duodenal fistula may also occur during surgery for duodenal diseases such as duodenal diverticulum.
(4) endoscopy and duodenal papillary incision: when duodenoscopic and retrograde cholangiopancreatography (ERCP) is performed for the duodenal papilla Oddi sphincter incision, due to improper force or Improper discriminating of the parts can easily damage the duodenum and cause duodenal fistula.
(5) Other operations: When performing surgery on organs near the duodenum, such as right hemicolectomy or nephrectomy, it is also possible to damage the duodenum and cause duodenal fistula.
Disease (15%):
(1) severe pancreatitis and pancreatic pseudocyst: because the pancreas is located in the duodenal ring, the fourth segment of the duodenum (uplift) is closely adjacent to the mid-pancreatic segment, and acute hemorrhagic necrotizing pancreatitis often Will affect the blood supply of the duodenum, the extravasation of the pancreatic juice will also digest the surrounding tissues of the duodenum, causing duodenal fistula, incision of the pancreatic pseudocyst may sometimes be combined with the duodenum Foreigner.
(2) Crohn's disease: Crohn's disease generally invades the ileocecal area and causes intestinal fistula in this area, but there are also reports of duodenal fistula caused by Crohn's disease in the duodenum.
(3) Intestinal tuberculosis: The duodenum is also invaded by tuberculosis and causes duodenal fistula.
Pathogenesis (15%):
1. Pathological classification There are many methods for classification of duodenal fistula. For example, the inner mouth of the intestinal fistula is directly attached to the surface of the skin, which is called a lip-shaped sputum; for example, there is a fistula between the inner and outer mouth of the intestinal fistula. It is called a tubular sputum. For example, the duodenal fistula is found earlier, that is, it does not form a lip sputum with the skin, and there is no formation of a fistula between the skin and a tubular sputum, but an intestine in the free abdominal cavity. The internal fistula, that is, the intraluminal hernia, the understanding of "intraluminal fistula" is the inevitable result of the early treatment of early diagnosis of extraintestinal fistula. Early detection of intracavitary fistula can be formed into tubular tendons by various methods to promote its own Healing, improve the self-healing rate of duodenal fistula, but if you focus on clinical diagnosis and treatment, duodenal fistula can be classified as follows, this classification method is convenient for clinicians to prevent and treat duodenal fistula .
(1) duodenal stump sputum: mainly occurs in patients with partial resection of the stomach, Billroth II type reconstruction, ie gastrojejunostomy or total gastrectomy. The cause of partial gastrectomy may be gastric ulcer or duodenal bulb. Ulcer, gastric cancer or stomach and duodenal bulb trauma, duodenal stump fistula and ulcer, cancer invasion is related to a wide range of lesions or a wide range of lesions, but also related to the dissatisfaction of stump suture embedding.
(2) Duodenal side spasm: The fistula is located on the side wall of the duodenum, and the gastric juice still passes through. This kind of external hemorrhoid is more difficult to heal by itself.
(3) Duodenal stump sputum: due to trauma or surgery, the duodenum is completely broken, the fistula can be divided, the proximal end, this kind of sputum can not heal itself.
(4) Duodenal anastomotic fistula; fistula is located in the gastric-duodenal anastomosis, duodenum-duodenal anastomosis or duodenum-jejunum anastomosis, often occurs in most of the stomach Patients undergoing gastro-duodenal anastomosis after resection and jejunum-duodenal anastomosis after duodenal trauma.
2. Pathophysiology Duodenal fistula is a high intestinal fistula. Due to the large loss of intestinal contents, it is also called high-flowing intestinal fistula. The pathophysiological changes that threaten the patient are as follows.
(1) Internal environment imbalance: continuous loss of large amounts of digestive juice can quickly cause dehydration, electrolyte and acid-base disorders. If not corrected in time, blood volume is reduced, leading to circulatory failure, or renal failure, resulting in azotemia.
(2) Malnutrition: Due to lack of digestion and absorption and energy supplementation, the loss of gastrointestinal fluid contains more protein, which can cause malnutrition, and hypoproteinemia reduces immunity.
(3) Infection: Infection is a major complication after the early water and electrolyte imbalance, especially the intra-abdominal infection, which makes the body in a high decomposition state, which can aggravate the stability of the internal environment, and the infection can not only cause malnutrition, but also Can cause stress ulcers or diffuse intestinal mucosal hemorrhage, causing shock, infection can lead to single organ or multiple organ failure, and it will increase the difficulty of intestinal fistula treatment, duodenal juice contains a lot of digestive enzymes, surrounding tissue Corrosion, melting, can cause skin erosion around the intestinal fistula, making the mouth difficult to heal; it may cause vascular rupture, causing massive bleeding and difficult to control.
3. The pathological process of pathological stage intestinal fistula can be divided into four phases:
(1) peritonitis: more than 3 to 5 days after trauma or surgery.
(2) Localized intraperitoneal abscess: more than 7 to 10 days after the onset of sputum.
(3) The formation and control period of the fistula: due to the degree of infection, the location of the fistula, the size and other factors, generally 10 to 30 days.
(4) The healing period of the fistula: due to the control of infection time and the type of fistula, about one month after the control of systemic infection, more than half of the patients with paralysis can self-heal, and a few self-healing within 2 to 3 months.
Prevention
Duodenal fistula prevention
1. Develop good habits, stop smoking and limit alcohol. Smoking, the World Health Organization predicts that if people no longer smoke, after five years, the world's cancer will be reduced by 1/3; secondly, no alcohol. Smoke and alcohol are extremely acidic and acidic substances. People who smoke and drink for a long time can easily lead to acidic body.
2. Don't eat too much salty and spicy food, do not eat foods that are overheated, too cold, expired and deteriorated. Those who are frail or have certain genetic diseases should eat some anti-cancer foods and high alkali content as appropriate. Alkaline foods maintain a good mental state.
Complication
Duodenal fistula complications Complications, malnutrition, peritonitis, abdominal abscess
1. The homeostasis imbalance: After the occurrence of duodenal fistula, the intestinal fluid is lost a lot, the discharge amount is >1000ml/24h, and the flow rate is up to 5000~6000ml per day. At this time, the circulating blood volume is seriously insufficient, and the electrolyte and pH are out of balance. .
2. Bleeding: intra-abdominal hemorrhage is an early complication of extraintestinal fistula, especially duodenal fistula and high jejunum fistula. The site of bleeding may be the blood vessels that are corroded and digested in the abdominal cavity, or may be the margin of the intestine, the granulation tissue of the fistula. There may also be bleeding due to gastrointestinal tract mucosal erosion.
3. Infection: Abdominal infection and systemic infection are the main causes of death in patients with extraintestinal fistula. Peritoneal infections include peritonitis, abdominal abscess and intra-abdominal organ infection. Early stage is mainly peritonitis. In the middle and late stage, abdominal abscess and abdominal internal organs are the main infections. In some patients, the intestinal fistula occurs on the basis of the original intra-abdominal infection. The intestinal fistula and the intra-abdominal infection coexist, forming a vicious circle, such as intestinal fistula complicated by severe pancreatitis.
4. Malnutrition: loss of digestive juice leads to incomplete digestion of food and poor absorption of nutrients.
Symptom
Symptoms of duodenal fistula Common symptoms Abdominal tenderness Abdominal tension Internal bleeding Abdominal pain Dehydration weight loss
Can be roughly divided into two cases: one is drainage after abdominal surgery; the other is not placed drainage (including elective major gastrectomy or abdominal closed injury, etc.), the former is easier to find early; There is a possibility of being misdiagnosed or missed.
1. Placement of the drainage in the abdominal cavity
It can be observed that a large amount of bile-like liquid flows out from the drainage port or the drainage tube, but the following characteristics are still to be noted.
(1) The occurrence time of sputum: generally occurs 5 to 8 days after surgery, but there are also cases in China that occur 18 days after surgery, 20 days, even 5 years after surgery, 10 years.
(2) Intestinal fluid outflow and abdominal muscle tension: The amount of local intestinal fluid outflow depends mainly on the type of duodenal fistula, location, size and pressure in the duodenum, lateral paralysis, and the intestinal fluid lost every day is 500. ~ 4000ml, the average is more than 2000ml, due to the placement of abdominal drainage, local abdominal muscle tension can not be significant; drainage is not smooth or did not place abdominal drainage, muscle tension is more obvious.
Sometimes the duodenal fistula has occurred, but the exudate is not much (but not diminished day by day), or no obvious bile-like fluid leaks, it is easy to be mistaken for local infection, the skin is corroded, or surge After the bile digestive juice (or food residue), the duodenal fistula is diagnosed. Therefore, patients with abdominal trauma or gastrectomy, such as wound exudate, should be further examined, observed, and vigilant. happened.
(3) fever: the general body temperature is between 38 ~ 39 ° C, the lead flow is smooth, the degree of fever is lighter, fever is the same as the outflow of intestinal fluid, is an important symptom.
(4) Hiccup: often due to leakage of intestinal fluid into the direction of the diaphragm, stimulate the diaphragm and produce hiccups, pay attention to observe the presence or absence of hiccups, which is helpful for early diagnosis, especially for those who do not place abdominal drainage, hiccup is an important signal.
(5) systemic symptoms: early dehydration and electrolyte imbalance, followed by weight loss, malnutrition and secondary infection symptoms, such as the formation of abscess in a certain part of the abdominal cavity (single, or more than two); Localized infections spread into systemic purulent infections, such as sepsis, toxic hepatitis, encephalitis, etc., which can be complicated by a single important organ failure, and even multiple organ failure.
2. The drainage cavity is not placed in the abdominal cavity
The leaked duodenal juice can flow into any part of the abdominal cavity and produce atypical abdominal symptoms. These symptoms are often covered by pain after surgery, absorbed by heat and other discomfort, and are easily overlooked. If you can pay attention to observation, most of them have Abdominal pain, hiccups and fever, as well as signs of varying degrees of peritonitis.
Examine
Examination of duodenal fistula
Gastroscopy
For patients with early extraintestinal fistula, 60% of diatrizoate 60-100ml can be injected orally or via a gastric tube. It can clearly show the intestinal fistula, whether it is in the intestinal lumen or leaking into the abdominal cavity. Absorption, angiography should dynamically observe the distribution of gastrointestinal motility and contrast agent, pay attention to the leakage of the contrast agent, the amount and speed of leakage, with or without branching fork and abscess, because 60% of the diatrizoate is also hyperosmotic Liquid, patients with good intestinal function will have a brief abdominal distension and increased stool frequency after examination. The intestinal tract has no motor function and can quickly absorb the contrast agent, and the symptoms of bloating are quickly relieved.
Because extraintestinal fistula is often accompanied by incomplete obstruction caused by inflammatory bowel obstruction or intestinal adhesion, it is clinically unsuitable to use sputum for gastrointestinal angiography. Barium angiography will aggravate the degree of digestive tract obstruction and make incomplete obstruction develop into a complete bowel. obstruction.
2. Tube angiography
When the fistula has been formed, the angiography can be performed first. Sometimes the gastrointestinal angiography can not meet the diagnostic requirements. The angiography of the fistula or the drainage orifice should be supplemented. 60% of the diatrizoate is still used as a contrast agent, directly through the skin. Inject the contrast agent, and then insert the catheter into the fistula and then angiography, so as to avoid the contrast agent directly entering the intestinal lumen and not showing the fistula and the surrounding conditions of the fistula, such as the fork, the abscess, etc., the direct contrast of the fistula is better than the digestive tract. Understand the condition of the fistula, regardless of the condition of the intestine, if you do not need to understand the situation of other intestinal fistula, if there is no obstruction and organic lesions, then no full gastrointestinal angiography is needed, a diagnosis can be confirmed by a fistula angiography. Develop a treatment plan.
3. Abdominal puncture
Take out bile-like intestinal fluid, sometimes containing food debris.
4. Oral bone charcoal or methylene blue solution test
The flow of dyed liquid from the wound can prove the presence of intestinal fistula. From the time of outflow, the color and amount of liquid, it is also possible to roughly estimate the size and position of the fistula. The amount of oral administration should be slightly larger for observation.
5. Abdominal plain film
The examination is helpful for the diagnosis of duodenal fistula. If the plain film shows a large amount of gas in the abdominal cavity or the liquid level is more likely to have intestinal fistula, the abdominal plain film may also indicate the presence or absence of combined intestinal obstruction, but this examination cannot Clear diagnosis.
6. CT examination
It is an ideal method for the clinical diagnosis of intestinal fistula, especially intestinal fistula with abdominal cavity and pelvic abscess. CT examination should be performed after oral angiography as much as possible. After filling the gastrointestinal tract with contrast agent, it helps to distinguish from the fluid accumulated outside the abdominal cavity. Even the fistula of the abscess and the intestine fistula can be found, and the "intraluminal fistula" without the opening of the abdominal wall is often difficult to be diagnosed by conventional gastrointestinal angiography and fistula angiography. This type of intestine can be found by continuous scanning of CT. Foreigner.
7.B-ultrasound
Although it can help to diagnose the presence or absence of effusion or abscess in the abdominal cavity, it is not accurate due to intestinal flatulence, and it does not help to diagnose the presence or absence of intestinal fistula.
Diagnosis
Diagnosis and identification of duodenal fistula
1. Qualitative diagnosis
It is not difficult to determine the diagnosis of duodenal fistula. The main reasons are: 1 recent abdominal surgery near the duodenum or duodenum, or upper abdominal trauma, 2 have clear symptoms of abdominal or retroperitoneal infection Such as abdominal pain, abdominal tenderness and rebound tenderness and fever and white blood cell rise, 3 sometimes intra-abdominal hemorrhage, 4 abdominal cavity puncture to extract yellow or grass green intestinal fluid, 5 abdominal drainage tube to drain intestinal fluid, or found food residue just eaten , 6 patients with oral methylene blue solution, nail purple solution and bone carbon powder, can be discharged through the abdominal cavity.
2. Positioning diagnosis
Defining the location and drainage of the duodenal fistula is an important part of the diagnosis. Imaging studies can provide relevant evidence. The abdominal stenosis or gastrointestinal angiography can often identify the location and number of the fistula, and the size of the fistula. The distance between the mouth and the skin, whether the mouth is accompanied by the drainage of the abscess and the fistula, and whether the intestine of the mouth of the mouth is unobstructed.
