duodenal fistula
Introduction
Introduction to duodenal fistula Duodenal fistula refers to a pathological pathway formed between the duodenum and other hollow organs in the abdominal cavity. The openings are located in the duodenum and corresponding hollow organs. The duodenum communicates with a single organ only as "simple duodenal fistula", and communication with two or more organs is called "complex duodenal fistula". The former is clinically more See, the latter is less common. During internal hemorrhoids, the contents of the duodenum and corresponding hollow organs can communicate with each other through the abnormal passage, thereby causing infection, bleeding, loss of body fluids (diarrhea, vomiting), water and electrolyte disorders, impaired organ function and nutrition. A series of changes such as bad. basic knowledge The proportion of sickness: 0.2% Susceptible people: no special people Mode of infection: non-infectious Complications: sepsis anemia
Cause
Duodenal fistula
(1) Causes of the disease
There are many causes of duodenal fistula formation, such as congenital developmental defects, iatrogenic injury, trauma, disease, etc. In the disease, it can be caused by duodenal lesions, such as duodenal diverticulitis, or It is caused by lesions in the adjacent organs of the duodenum, such as chronic colitis, gallstones, etc. A group of data reports that the most common cause of duodenal fistula is iatrogenic injury, followed by stones, openness and Pathological factors such as closed injury, tumor, tuberculosis, ulcer disease, Crohn's disease and radiation enteritis are less than 10%.
Congenital factors (5%):
The true congenital duodenal fistula is extremely rare. Only a few cases have been reported. Xu Minhua et al reported a case of congenital gallbladder duodenal fistula. During operation, there was an abnormal channel between the duodenum and the gallbladder. Both are smooth and have no scars.
Iatrogenic injury (20%)
The duodenal fistula caused by iatrogenic injury generally exists between the duodenum and the common bile duct. It is more commonly used in the biliary tract surgery to detect the lower end of the common bile duct by using the rigid biliary exploration strip. In small cases, the force was too large to penetrate the common bile duct and the duodenal wall to form the common bile duct duodenal papilla. Xue Zhaoxiang et al reported 8 cases of biliary duodenal fistula after biliary tract surgery. Due to the inflammatory stenosis of the common bile duct, the introduction of biliary tract strips is difficult to conduct, suggesting that the use of probes in the exploration of common bile duct stenosis should be cautious, violent exploration should not be used to reduce iatrogenic injury, and then the common bile duct T When the tube is drained, the T-shaped tube is placed too low, and the tube placement time is too long. The T-shaped tube compresses the duodenal wall to cause ischemia, necrosis, and perforation, causing duodenal fistula in the common bile duct. Sexual injury, Fan Xianjun and other reports of 2 cases of biliary T-tube compression duodenal perforation after the biliary tract, the common bile duct T-tube drainage and duodenal perforation formed duodenal fistula, suggesting: common bile duct T When the tube is drained, the position should not be placed too low. Were placed in the T-shaped pipe connected between the duodenum and small fixed omentum, duodenum cut off to avoid compression, causing secondary injury.
Stones (20%):
Duodenal fistula often occurs between the duodenum and the biliary system, most of which is the result of perforation of gallstones, more than 90% of the gallbladder duodenal fistula, common bile duct duodenal fistula, gallbladder twelve Intestinal colon fistula, all from chronic cholecystitis, cholelithiasis, internal hemorrhoids in the gallbladder, pancreas, duodenal confluence area, and more biliary pancreatic disease, cholecystitis, recurrent attacks of cholelithiasis lead to gallbladder or bile duct The adhesion between an organ and the surrounding organs is the basis for the later formation of internal hemorrhoids. On the basis of adhesion, the stones in the gallbladder compress the gallbladder wall to cause ischemia, necrosis, perforation and communication with another organ to form internal hemorrhoids, gallbladder The neck is one of the most common sites for perforation to form internal hemorrhoids. This is relatively small compared with the cystic duct. The gallbladder is strongly contracted by inflammation or stones. The neck is under greater pressure. The most common organ involved in recurrent cholecystitis is ten. In the duodenum, colon and stomach, when the biliary system adheres to the duodenum due to inflammation, the gallstone can press the duodenum to cause necrosis of the intestinal wall, perforation, self-reduced drainage, and gallstones are discharged into the duodenum. Into the gallbladder duodenal fistula, common bile duct duodenal fistula, gallbladder duodenal colon fistula, this due to stone incarceration, obstruction, infection caused by duodenal perforation self-decompression formed by internal hemorrhoids, often A special process of the body's self-discharging or a complication of gallstones can sometimes cause gallstone obstruction.
Peptic ulcer (20%):
Chronic penetrating ulcer of the duodenum, often caused by chronic inflammation to perforate adjacent organs to form internal hemorrhoids, such as ulcers located in the anterior wall or side wall of the duodenum can penetrate into the gallbladder to form the gallbladder duodenum, and the ulcer is located in the posterior wall of the duodenum and penetrates into the common bile duct, causing duodenal duodenal fistula. Duodenal ulcer can also penetrate the colon downwards to cause duodenal colon fistula, or gallbladder 12 Refers to the intestinal colon fistula, there are also reports of penetrating duodenal fistula formed by penetrating pyloric ulcer, the hepatic portal aneurysm and the duodenal descending close adhesion to the duodenum and causing massive bleeding It is also a special duodenal fistula. Due to the early treatment of duodenal ulcer by antisecretory drugs, duodenal fistula caused by duodenal ulcer is currently very rare in clinical practice.
Malignant tumors (10%):
Duodenal fistula caused by malignant tumor is also called malignant duodenal fistula, mainly duodenal cancer infiltrating colonic hepatic or transverse colon, or colonic liver cancer to the duodenum. Four sections of infiltration perforation, Hershees collected 37 cases of duodenal-colon fistula, 19 of which originated from colon cancer. In recent years, it has been reported in the country that duodenal fistula is a rare complication of colon cancer, and another twelve fingers Hodgkin's disease in the intestine or colon, or cancer of the gallbladder can also cause duodenal fistula. As the incidence of cancer increases, reports of duodenal fistula caused by malignant tumors are increasing.
Inflammatory disease (5%):
Due to chronic inflammation, infiltration and perforation into adjacent organs can form internal hemorrhoids. Inflammatory diseases include duodenal diverticulitis, Crohn's disease, ulcerative colitis, radiation enteritis and intestinal specific infections, such as abdominal tuberculosis. Duodenal colon fistula or gallbladder duodenal colon fistula.
(two) pathogenesis
Pathological changes of congenital duodenal fistula: the bottom of the abnormal passage is the gallbladder mucosa, the neck is the duodenal gland, and the upper part of the gallbladder gland and the duodenal gland are visible 0.5 cm above, which is confirmed to be congenital. Abnormalities, Wang Yuan and Tan Weilin (1988) reported two surgically confirmed congenital duodenal fistulas, all of which were adult females. The internal fistula occurred between the third part of the duodenum and the transverse colon, given the digestive system. The embryological study occurred, and the third half of the duodenum and the second intestine of the transverse colon were evolved from the midgut. Therefore, from the perspective of embryogenesis, if the midgut is abnormal during embryonic development, then It is entirely possible to form such guilt.
Prevention
Duodenal fistula prevention
Eat a reasonable diet, quantify on time, protect the digestive tract and avoid damage. Stop eating all the stimulating foods such as fried foods, spicy foods, strong tea coffee, etc.
Complication
Duodenal fistula complications Complications septic anemia
During internal hemorrhoids, the contents of the duodenum and corresponding hollow organs can communicate with each other through the abnormal passage, thereby causing infection, bleeding, loss of body fluids (diarrhea, vomiting), water and electrolyte disorders, impaired organ function, and nutrition. A series of changes such as bad.
1. Infection is the most common complication, and sepsis can occur in severe cases.
2. Combine water and electrolyte disorders.
3. Bleeding, anemia is also a common complication.
Symptom
Symptoms of duodenal fistula Common symptoms Hernia hemorrhagic biliary colic secondary infection weak abdominal mass upper abdominal pain diarrhea cachexia nausea
After the occurrence of duodenal fistula, whether the patient has symptoms or not, should be different depending on the different hollow organs that communicate with the duodenum. The organ that communicates with the duodenum is different, and the consequences of the internal hemorrhoids on the body. Differently, the resulting symptoms often vary greatly depending on the organ being damaged. For example, duodenal biliary fistula is the main lesion of biliary tract infection, so the clinical symptoms are mainly liver damage; and duodenum Colonic fistulas are mainly gastrointestinal symptoms such as diarrhea, vomiting, and malnutrition.
Gastroduodenal fistula
Gastroduodenal fistula can occur in the stomach and duodenal bulb, between the transverse and ascending parts, almost all due to benign gastric ulcer secondary infection, adhesion, and then perforation break into the adhesion of the four fingers Intestinal spheroids, or local abscesses formed after perforation of the stomach, and then break into the duodenum or ascending part of the duodenum.
After the formation of gastroduodenal fistula, it has little interference with the physiological functions of the body. Generally, there are no obvious symptoms. Most patients have concealed the clinical manifestations of sputum due to long-term severe ulcer symptoms; a small number of patients occasionally have gastric output. obstruction.
2. Duodenal gallbladder fistula
Symptoms are similar to cholecystitis, such as hernia, nausea and vomiting, anorexia oil, indigestion, sometimes chills and fever, abdominal pain, jaundice and cholangitis, cholelithiasis, sometimes duodenal obstruction, and gallstone Obstruction occurs in the terminal ileum or ileocecal valve of the stenosis of the intestine, which is manifested as acute mechanical intestinal obstruction. If it is caused by cancer, it is mostly advanced, its symptoms are heavier, and cachexia is soon.
3. Duodenal common bile duct
Usually only symptoms of ulcer disease appear, and a small number of patients with acute suppurative cholangitis can be admitted to the hospital.
4. Duodenal pancreatic fistula
Duodenal pancreatic fistula often precedes the symptoms of pancreatic abscess or pancreatic cyst, so it may be possible to ask for a history of upper abdominal masses. Second, most have severe symptoms of gastrointestinal bleeding. It is not easy to confirm the diagnosis before surgery. Berne and Edmondson It is believed that the digestive tract pancreatic fistula has three related clinical processes, that is, an intra-abdominal mass after pancreatitis and sudden severe gastrointestinal bleeding, and should be alert to the occurrence of internal hemorrhoids; when the intra-abdominal mass disappears, it is often formed by internal hemorrhoids. On the day of this, this experience can be used as a reference for diagnosis.
5. Duodenal colon fistula
Benign duodenal colon fistula often has upper abdominal pain, weight loss, fatigue, increased appetite, stool containing undigested food or severe watery diarrhea, and some patients with vomiting, can smell the feces in the vomit Stinky, combined with previous medical history has diagnostic significance, the time of internal hemorrhoids, according to statistics from 1 week to 32 weeks, most (more than 70%) patients at least 3 months after the internal hemorrhoids were diagnosed and surgery, guilty existence time The longer the symptoms, the more sudden the symptoms and the more serious the consequences.
The most prominent symptom of congenital duodenal colon fistula is diarrhea, which often occurs from birth. No history of peritonitis, tumor and abdominal surgery can be found in the history of the congenital internal hemorrhoid on the duodenal side. Lower, and there is no obstruction at the distal end of the medial malleolus, so fecal vomiting and bloating are rare. If there is no complication, abdominal pain will not occur. Pay attention to the difference between non-congenital benign duodenal colon fistula.
If the duodenal colon fistula caused by malignant tumor infiltration and perforation, in addition to basically having the above symptoms, the condition is heavier, the deterioration is faster, and at the same time there are corresponding symptoms of malignant tumors.
6. Duodenal pyelonephritis (ureter)
Clinically, there may be a peri-renal abscess, that is, a low back pain on the side of the disease, a local mass, a pain to the thigh or testicle, and a positive lumbar muscle stimulation. After that, there may be bubbles in the urine, or urine turbidity, or food residue. And frequent urination, urgency, dysuria and other bladder irritation.
If there is a sudden water sample, purulent diarrhea accompanied by the disappearance of the lumbar mass, often prompted the occurrence of internal hemorrhoids, at this time, low back pain, often dehydration and hematuria, in addition to the more prominent gastrointestinal symptoms, such as nausea, Vomiting and anorexia, kidney stones are very rare from the anus. Those who fail to get timely treatment are chronically ill, fatigue and anemia. Sometimes they can cause obvious sepsis. Patients always have symptoms of urinary tract infection. Some patients have Hyperchloremia acidosis.
Ning Tianshu and others have reported a congenital ureteral duodenal fistula complicated with urinary tract tsutsugamushi disease. The patient has been diagnosed from the age of 4 to the age of 18, and it is estimated that about 400 mites are discharged from the urethra. Healing, the Department of Urology, the First Affiliated Hospital of Wuhan Medical College (1977) reported that a 5-year-old man with right ureteral duodenal fistula also had a history of mites. Because of the mites, the first thought was the low intestinal fistula. It is easy to cause misdiagnosis. This operation found that there is not only a fistula between the upper part of the right ureter and the duodenum, but also a cross fistula at the 1 cm of the right lower pole of the right kidney and the descending part of the duodenum. It is special, so it is urinary tract tsutsugamushi disease. The analysis can not be limited to the diagnosis of low intestinal fistula.
Examine
Examination of duodenal fistula
Choose to do blood, urine, stool, routine, biochemical and electrolyte tests.
X-ray inspection
Includes abdominal fluoroscopy, abdominal plain film and gastrointestinal dips.
(1) Abdominal fluoroscopy and abdominal plain film: Sometimes the gas in the gallbladder can be seen, which is an indirect basis for the diagnosis of duodenal fistula, but it should be differentiated from gas cholecystitis caused by aerogenic bacillus, duodenal pyelonephritis ( When the ureter is sputum, the plain film of the abdomen shows air shadows and X-ray opaque stones (25% to 50%).
(2) digestive tract barium angiography: gastrointestinal tract sputum angiography can provide a direct basis for the presence of internal hemorrhoids, can show the size of the fistula in the duodenum, the direction of travel, with or without sputum and multiple sputum.
1 upper digestive tract barium angiography: visible images are:
A. Gastroduodenal fistula, gastric pyloric tube malformation and pyloric duct fistula parallel thereto.
B. Duodenal gallbladder fistula, gallbladder or biliary tract have sputum and/or gas, mucosal signs have mucosal signs, the former is more diagnostic, and in addition, the development of gallbladder ostomy is also one of the indirect evidence.
C. Duodenal colon fistula, the colon has an expectorant filling.
D. Duodenal pancreatic fistula, tincture into the pancreas area.
2 lower digestive tract barium enema: It can be found that the sputum agent directly enters the duodenum or biliary system from the colon, and the correct diagnosis rate of duodenal colon fistula can reach more than 90%. The location of the fistula, combined with the mucosal lines shown in the observation, helps to identify duodenal colon fistula, jejunal colon fistula, colonic pancreatic fistula and colonic renal pelvis.
(3) intravenous pyelography: duodenal renal pelvis (ureter) patients with this examination, due to the destruction of the function of the kidney, often can not show the location of the sputum, but from the disease of the kidney can provide a diagnosis of sputum And the treatment also needs to understand the function of the kidney through angiography, so there is still the significance of angiography.
2. Ultrasound, CT, MRI examination
From different angles, different parts can show the location of the intrahepatic and extrahepatic bile duct stones and digestive tract lesions, the extent and the morphological changes of the bile duct, and the diagnosis of duodenal fistula can only provide indirect diagnostic basis, such as biliary gas. The colon is infiltrated into the duodenum.
3. ERCP check
The endoscope can directly observe the fistula of the duodenum, and at the same time inject the contrast agent, which can show the full appearance of the fistula, the size of the fistula, and the diagnosis rate can reach 100%. It is the most reliable diagnostic method for duodenal fistula. .
4. Endoscopy
(1) colonoscopy: the opening of the abnormal passage of the gastrointestinal tract can be found and differentially diagnosed. After the duodenoscopy enters the duodenum, the mucosa is ring-shaped folds, soft and smooth, and the nipple is located in the descending segment of the duodenum. On the inside of the longitudinal ridge of the fold, the general mouth is located above the nipple opening, the shape is mostly irregular star shape, no normal nipple shape and opening characteristics, when the mouth is covered by the mucous membrane is not easy to find, but inserted from the nipple opening Tube, the catheter can be folded back from the fistula to the intestine, and the cannula is intubated from the top of the nipple. The abnormal passage is developed and diagnosed. At this time, the mirror is close to the fistula, and bile or other liquid overflows. Intestinal fistula should be distinguished from the duodenal diverticulum. The diverticulum can also have a hole near the duodenal papilla, but the edges are relatively neat, and the openings are mostly round. There are often food residues in the cave, and the residue can be removed after the residue is removed. When seeing the bottom of the diverticulum, the catheter is inserted into the cavity and folded back into the intestine. The contrast agent can be completely overflowed. At the same time, the contrast agent can be seen in the intestine without abnormal channel development. A group of reports report 47 cases of common bile duct duodenal fistula. , There were 5 cases of duodenal diverticulum, and 1 case of nipple and fistula were located in the cavity of the large diverticulum. Immediately after endoscopy, the sputum was examined and confirmed to be the duodenal descending medial large diverticulum. The examination can clearly locate the duodenal colon fistula, and can observe the size of the fistula, biopsy to determine the nature of the primary lesion, and provide a basis for selecting the surgical approach.
(2) Laparoscopy: It can also be used as a means of diagnosis and treatment of duodenal fistula, and has broad application prospects.
(3) cystoscopy: suspected duodenal renal pelvis (ureter) sputum, in addition to the signs of cystitis, this can be seen in the ureteral opening of the disease side with bubbles or purulent debris; or After the intubation of the diseased side ureter, the contrast agent can be used to detect the contrast agent in the duodenum. The current diagnosis mainly relies on retrograde pyelography, and nearly 2/3 of the patients are positive.
5. Bone charcoal powder test
Oral bone charcoal powder, black charcoal is discharged from the urine after 15 to 40 minutes. This test can only confirm the presence of internal hemorrhoids between the digestive tract and the urinary tract, but the location of the sputum cannot be determined.
Diagnosis
Diagnosis and identification of duodenal fistula
Duodenal fistula, preoperative diagnosis is more difficult, because most of the duodenal fistula lack of characteristic performance, the rate of missed diagnosis is extremely high, Yao Xingrong reported 10 cases of gallbladder duodenal fistula, preoperative diagnosis of 7 cases Cholecystitis, gallstones, 3 cases diagnosed as intestinal obstruction, improve the correct diagnosis rate of duodenal fistula, should pay attention to the following aspects:
1. History:
Correct and detailed past history, current medical history is a reliable source of information for clinical diagnosis. Those with the following medical history should consider the possibility of presence of duodenal fistula.
(1) A history of recurrent biliary tract diseases, especially those with biliary colic, jaundice, and sudden disappearance.
(2) The previous color Doppler ultrasound or B-ultrasound showed a large stone in the gallbladder. The recent review showed that the stone had disappeared or was displaced in the intestinal lumen.
(3) long-term abdominal pain, diarrhea, weight loss, fatigue and varying degrees of malnutrition.
2. Auxiliary inspection:
The diagnosis of duodenal fistula often requires imaging examination, such as X-ray examination, color Doppler ultrasound or B-ultrasound, CT, MRI, ERCP, etc., can provide direct or indirect imaging diagnosis basis, or endoscopy The diagnosis of the abnormal passage of the gastrointestinal tract can be confirmed.
