fistula

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Related to fistulas, fistulae: Obstetric fistula, Fistula in ano

Fistula

 

Definition

A Fistula is a permanent abnormal passageway between two organs in the body or between an organ and the exterior of the body.

Description

Fistulas can arise in any part of the body, but they are most common in the digestive tract. They can also develop between blood vessels and in the urinary, reproductive, and lymphatic systems. Fistulas can occur at any age or can be present at birth (congenital). Some are life-threatening, others cause discomfort, while still others are benign and go undetected or cause few symptoms. Diabetics, individuals with compromised immune systems (AIDS, cancer) and individuals with certain gastrointestinal diseases (Crohn's disease, inflammatory bowel disease) are at increased risk of developing fistulas.
Fistulas are categorized by the number of openings they have and whether they connect two internal organs or open through the skin. There are four common types:
  • Blind fistulas are open on one end only.
  • Complete fistulas have one internal opening and one opening on the skin.
  • Horseshoe fistulas are complex fistulas with more than one opening on the exterior of the body.
  • Incomplete fistulas are tubes of skin that are open on the outside but closed on the inside and do not connect to any internal structure.

Fistulas of the digestive tract

Anal and rectal fistulas develop in the wall of the anus or rectum. They connect the interior of the body to one or several openings in the skin. Anal and rectal fistulas almost always begin as an inflammation in an anal gland. The inflammation then moves into muscle tissue and develops into an abscess. In about half of all cases, the abscess develops into a fistula, degrading the muscle until an opening in the skin is created. About 9 people of every 100,000 develop anal fistulas, with men almost twice more likely to develop the condition than women. Although they may develop at any age, the average age for the development of anal fistulas is 38.
Intestinal fistulas can develop in both the large and small intestine. They are commonly associated with diseases such as inflammatory bowel disease(IBD) and Crohn's disease.
Tracheoesophageal fistulas (TEF) are usually birth defects. The windpipe, or trachea, is abnormally connected to the esophagus. This allows air to enter the digestive system and makes it possible to breathe food into the lungs (aspiration). In many cases, the esophagus is also incomplete, causing immediate feeding problems. There are several types of TEFs categorized by where the fistula is located and how the esophagus and trachea are connected, but all are life-threatening and require prompt surgery to repair. TEFs occur in about one of every 1,500-3,000 births.

Fistulas of the urinary and reproductive tract

The most common type of fistula involving these systems is a vesicovaginal fistula, in which the woman's vagina is connected to the urinary bladder. This causes leakage of urine from the vagina and results in frequent vaginal and bladder infections. Fistulas may also develop between the vagina and the large intestine (a enterovaginal fistula) so that feces leaks from the vagina. Although both these types of fistulas are uncommon in the developed world, they are common in poor developing countries and result from long, difficult labor and childbirth, especially in very young girls. As a result, they are sometimes referred to as obstetric fistulas.
Some experts suggest that in parts of Africa, as many as 3-4 women develop these fistulas out of every 1,000 births. Others estimate that as many as 2 million women worldwide are living with unrepaired obstetric fistulas. If left unrepaired, obstetric fistulas cause women to constantly leak urine and feces. As a result, they become social outcasts, causing them extreme hardship and psychological trauma.

Fistulas of the circulatory system

Arteriovenous fistulas (AVF) can develop between an artery and a vein in any part of the body. These fistulas vary in size, length, and frequency. Arteries contain blood carrying oxygen to all parts of the body, while veins carry blood that has given up its oxygen back to the lungs. Connections between arteries and veins cause changes in blood pressure that result in abnormal development of the walls of the arteries and abnormal blood flow. Arteriovenous fistulas that are present at birth are sometimes referred to as arteriovenous malformations (AVMs). Many arteriovenous fistulas are present, but not evident at birth, and become obvious only after trauma. AVFs can also be acquired from penetrating trauma.

Causes and symptoms

The causes and symptoms of fistulas vary depending on their location. Anal and rectal fistulas are usually caused by an abscess. Symptoms include constant throbbing pain and swelling in the rectal area. Pus is sometimes visible draining from the fistula opening on the skin. Many individuals have a fever resulting from the infection causing the abscess.
Vaginal fistulas are caused by infection and trauma to the tissue during childbirth. They are easily detected, because the woman smells unpleasant and leaks urine or feces through her vagina. Rarely these fistulas may develop as a complication of hysterectomy.
Tracheoesophageal fistulas are the result of errors in the development of the fetus. They are evident at birth, because the infant is unable to swallow or eat normally and are considered a medical emergency that requires surgery if the infant is to survive.
Arteriovenous fistulas are most often congenital defects. Symptoms vary depending on the size and location of the fistula. Often the skin is bright pink or dark red in the area of the fistula. Individuals may complain of pain. The pain is a result of some tissues not receiving enough oxygen because of abnormal blood flow.

Diagnosis

Tests use to determine the presence of a fistula vary with the location of the fistula. When there is an opening to the outside, the physician may be able to see the fistula and probe it. Various imaging studies such as x rays, CT scans, barium enemas, endoscopy, and ultrasonography are used to locate less visible fistulas.

Treatment

Anal and rectal fistulas are treated by draining the pus the infected area. The individual also is usually given antibiotics to help prevent recurrence of the abscess. If this fails to heal the fistula, surgery may be necessary.
Intestinal fistulas are treated first by reducing the inflammation in the intestine and then, if necessary with surgery. Treatment varies considerably depending on the degree of severity of symptoms the fistula causes. TEFs are always treated with surgery. Obstetric fistulas must also be repaired with surgery. The treatment of arteriovenous fistulas depends on the size and location of the fistula and usually includes surgery.

Alternative treatment

No effective alternative treatments for fistulas are known.

Prognosis

The outcome of fistulas depends on the type and cause of the condition. Surgical repair of obstetric fistulas is almost always successful. Unfortunately, many women in developing countries do not have access to this type of surgery. Treatment of anal and rectal fistulas is almost always successful, although fistulas may recur in up to 18% of individuals. The outcome of surgery on TEFs is highly variable, especially since infants born with this condition often have other developmental abnormalities that may affect the outcome of fistula repair. The degree of successful repair of arteriovenous fistulas depends on their size and location. Uncontrolled bleeding is the most common complication of surgery to repair AVFs.

Prevention

Obstetric fistulas are the only preventable fistulas. These can be prevented with good prenatal and childbirth care and by avoiding pregnancy in very young girls. Although anal and rectal fistulas are not preventable, their damage can be minimized by prompt drainage and treatment.

Key terms

Abscess — A collection of pus surrounded by inflamed, infected tissue.
Lymphatic system — The part of the circulatory system that carries lymph, a clear fluid that is involved in immune system response.

Resources

Organizations

American Society of Colon and Rectal Surgeons. 85 W. Algonquin Road, Suite 550, Arlington Heights, IL 60005. 847-290-9184. http://www.facrs.org.

Other

Legall, Ingrid. Anal Fistulas and Fissures, 11 June 2004 [cited 16 February 2005]. http://www.emedicine.com/emerg/topic495.htm.
"Fistula." Medline Plus Medical Encyclopedia 29 October 2003 [cited 16 February 2005]. http://www.nlm.nih.gov/medlineplus/ency/article/002365.htm.
Morasch, Mark D. and Dipen Maun. Arteriovenous Fistulas, 24 October 2003 [cited 16 February 2005]. http://www.emedicine.com/med/topic169.htm.
Zagrodnik, Dennis II. Fistula-in-Ano, ii June 2004 [cited 3 March 2005]. http://www.emedicine.com/med/topic2710.htm.

fistula

 [fis´tu-lah] (pl. fistulas, fis´tulae) (L.)
any abnormal tubelike passage within body tissue, usually between two internal organs or leading from an internal organ to the body surface. Some fistulas are created surgically for diagnostic or therapeutic purposes; others occur as result of injury or as congenital abnormalities. Among the many kinds of fistulas, the anal type (fistula in ano) is one of the most common. It generally develops as a result of a break or fissure in the wall of the anal canal or rectum, or an abscess there. Treatment is by surgery.

In women, difficult labor in childbirth may result in formation of a vesicovaginal fistula between the bladder and the vagina with resulting leakage of urine into the vagina. In a vesicointestinal fistula, there is leakage of urine from the bladder into the intestine. In a rectovaginal fistula, feces escape through the wall of the anal canal or rectum into the vagina. This condition, formerly a serious hazard of childbirth, is now rare; like other kinds of fistula, it can be corrected by surgery.

With the types of fistulas described here, typical symptoms are pain in the affected region and an abnormal discharge through the skin near the anus or through the vagina. Fistulas at different places of the body may be caused by tuberculosis, actinomycosis (a fungus infection), the presence of diverticula, or certain other serious diseases, and the fistula itself may be a site of infection and discomfort.
abdominal fistula one between a hollow abdominal organ and the surface of the abdomen.
anal fistula (fistula in a´no) one opening on the cutaneous surface near the anus, which may or may not communicate with the rectum.
arteriovenous fistula one between an artery and a vein, either pathologic (such as a varicose aneurysm) or surgically created to ensure an access site for hemodialysis. The site must be allowed 6 to 8 weeks to mature before it can be cannulated. Such a fistula may be the anastomosis of a natural artery and vein, a bovine graft, or a synthetic polytetrafluoroethylene (PTFE) graft. The bovine graft is taken from the bovine carotid artery and anastomosed to the vein and artery of the patient. In a PTFE graft, fibers are woven into a mesh called Gore-Tex and made into a sleeve and flange; this is available in a variety of sizes.

Precautions necessary to insure patient safety when caring for an individual with an arteriovenous fistula include frequent assessments for adequate circulation in the fistula and the distal extremity. A bruit or thrill can be heard over the access site. Blood pressure measurements, withdrawal of blood, injections, and administration of intravenous fluids should not be done on the extremity with such a fistula.
Internal arteriovenous fistulas.
blind fistula one open at one end only, opening on the skin (external blind fistula) or on an internal surface (internal blind fistula).
branchial fistula a persistent pharyngeal groove (branchial cleft).
Brescia-Cimino fistula an arteriovenous fistula for hemodialysis access, connecting the cephalic vein and radial artery.
bronchopleural fistula one between a bronchus and the pleural cavity, causing an air leak into the pleural cavity; sometimes seen as a complication of empyema, fibrosis, or pneumonia.
cerebrospinal fluid fistula one between the subarachnoid space and a body cavity, such as from head trauma or bone erosion, with leakage of cerebrospinal fluid, usually in the form of rhinorrhea or otorrhea.
complete fistula one extending from the skin to an internal body cavity.
craniosinus fistula one between the cerebral space and a paranasal sinus, permitting escape of cerebrospinal fluid into the nose.
Eck's fistula an artificial communication made between the portal vein and the vena cava.
enterocutaneous fistula see enterocutaneous fistula.
enterovesical fistula one connecting some part of the intestine with the urinary bladder; called also vesicoenteric f.
fecal fistula one between the colon and the external surface of the body, discharging feces.
gastric fistula
1. one communicating between the stomach and some other body part.
2. a passage created artificially through the abdominal wall into the stomach.
horseshoe fistula one near the anus, having a semicircular tract with both openings on the skin.
incomplete fistula blind fistula.
perilymph fistula rupture of the round window with leakage of perilymph into the inner ear, so that changes in middle ear pressure directly affect the inner ear, causing sensorineural deafness as well as dizziness, vertigo, nausea, and vomiting. Head trauma and dramatic changes in atmospheric pressure are the most common causes. The usual treatment is restriction in activity (sometimes with complete bed rest), so that the fistula can heal. Surgical repair may be necessary, consisting of placement of a graft over the defect.
pilonidal fistula pilonidal sinus.
pulmonary arteriovenous fistula a congenital fistula between the pulmonary arterial and venous systems, allowing unoxygenated blood to enter the systemic circulation.
rectovaginal fistula one between the rectum and vagina.
rectovesical fistula one between the rectum and urinary bladder.
salivary fistula one between a salivary duct or gland and the cutaneous surface, or into the mouth through an abnormal pathway.
thoracic fistula one communicating with the thoracic cavity.
umbilical fistula one communicating with the intestine or urachus at the umbilicus.
urinary fistula any fistula communicating between the urinary tract and another organ or the surface of the body.
vesicoenteric fistula (vesicointestinal fistula) enterovesical fistula.
vesicovaginal fistula one from the bladder to the vagina.

fis·tu·la

, pl.

fis·tu·lae

,

fis·tu·las

(fis'tyū-lă, -tyū-lē, -tyū-lăz),
An abnormal passage from one epithelial surface to another epithelial surface.
[L. a pipe, a tube]

fistula

/fis·tu·la/ (fis´tu-lah) pl. fistulas, fis´tulae   [L.] an abnormal passage between two internal organs or from an internal organ to the body surface.
Enlarge picture
Various types of fistulae, designated according to site or to the organs with which they communicate. (A), Genitourinary fistulae; (B), anal fistulae.

anal fistula  one from the anus to the skin, sometimes communicating with the rectum.
arteriovenous fistula 
1. one between an artery and a vein.
2. a surgically created arteriovenous connection that provides a site of access for hemodialysis tubing.
blind fistula  one open at one end only, opening on the skin (external blind f.) or on an internal mucous surface (internal blind f.) .
branchial fistula  a persistent pharyngeal groove (branchial cleft).
cerebrospinal fluid fistula  one between the subarachnoid space and a body cavity, with leakage of cerebrospinal fluid, usually as otorrhea or rhinorrhea.
colonic fistula  one connecting the colon with the body surface or another organ.
craniosinus fistula  one between the cerebral space and one of the sinuses, permitting escape of cerebrospinal fluid into the nose.
enterovesical fistula  one connecting the urinary bladder with some part of the intestines.
fecal fistula  a colonic fistula that discharges feces on the body surface.
gastric fistula  one communicating with the stomach, either pathologically or surgically created through the abdominal wall.
genitourinary fistula  one between two organs of the urogenital system or between one of those organs and some other system.
incomplete fistula  blind f.
intestinal fistula  one communicating with the intestine; sometimes surgically created through the abdominal wall.
perilymph fistula  rupture of the round window with leakage of perilymph into the middle ear, causing sensorineural hearing loss.
pulmonary arteriovenous fistula  a congenital fistula between the pulmonary arterial and venous systems, so that unoxygenated blood enters the systemic circulation.
salivary fistula  one communicating with a salivary duct.
tracheoesophageal fistula  one connecting the trachea and esophagus, either pathologically or created surgically to restore speech after laryngectomy.
umbilical fistula  one communicating with the colon or the urachus at the umbilicus.

fistula

(fĭs′chə-lə)
n. pl. fistu·las or fistu·lae (-lē′)
1. A duct or passage resulting from injury, disease, or a congenital disorder that connects an abscess, cavity, or hollow organ to the body surface or to another hollow organ.
2. Such a passage that has been created intentionally, especially a surgically constructed connection between an artery and a vein that is used for vascular access in hemodialysis.

fistula

[fis′choo͡lə, -chələ] pl. fistulae, fistulas
Etymology: L, pipe
an abnormal passage from an internal organ to the body surface or between two internal organs, such as a hepatopleural or pulmonoperitoneal fistula. Fistulas may occur in many sites from the gingiva to the anus. They may be caused by a congenital defect, injury, infection, spreading of a malignant lesion, surgery, radiotherapy of a cancerous growth, or trauma during childbirth. They also may be created to achieve therapeutic purposes or obtain body secretions for physiological studies. An arteriovenous fistula is commonly created to gain access to the patient's bloodstream for hemodialysis. Anal fistulas that result from rupture or drainage of abscesses may be treated by fistulectomy or fistulotomy; fistulas between the vagina and bladder, urethra, ureter, or rectum may be repaired surgically, but the results are not always successful. fistular, fistulate, fistulous, adj.

fistula

Surgery An abnormal communication or conduit between one internal organ and another or with the skin surface. See Gastrointestinal fistula, Inner ear fistula, Urinary fistula.

fis·tu·la

, pl. fistulae, pl. fistulas (fis'tyū-lă, -lē, -lăz)
An abnormal passage from one epithelialized surface to another, either congenital, caused by disease or injury, or created surgically.
[L. a pipe, a tube]

fistula

An abnormal communication between any part of the interior of the body and the surface of the skin, or between two internal organs. Fistulas may be present at birth (congenital) or may arise as a result of disease processes such as abscesses or cancer.

fistula

abnormal opening or canal between a hollow organ and the body surface

fistula

An unnatural passage from an organ to the body surface or from one organ to another.
carotid-cavernous fistula An abnormal interconnection between the internal carotid artery and the cavernous sinus. It may be caused by trauma to the skull or orbit, vascular disease or systemic hypertension. Common signs are pulsating proptosis, eye redness, diplopia, dilated epibulbar vessels and bruit. The pressure in the orbital veins is elevated as a result of the flow of arterial blood into the cavernous sinus.
lacrimal fistula An abnormal opening from the skin onto any part of the lacrimal passage, although most often the lacrimal sac. It may follow a severe acute dacryocystitis.

fis·tu·la

, pl. fistulae, pl. fistulas (fis'tyū-lă, -lē, -lăz)
An abnormal passage from one epithelial surface to another.
[L. a pipe, a tube]

fistula (fis´tyoolə),

n an abnormal tract connecting two body surfaces or organs or leading from a pathologic or natural internal cavity to the surface. The tract may be lined with epithelium.
Enlarge picture
Fistula.
fistula, alveolar,
n See parulis.
fistula, arteriovenous,
fistula, branchial,
n a fistula associated with a branchial cyst; usually seen on the lateral surface of the neck.
fistula, dental,
n See parulis.
fistula, of lip,
n a congenital malformation in which there is a deep pit or fistula on the mucosa of the lip; often bilateral and usually found on the lower lip.
fistula, oroantral,
n an opening between the maxillary sinus and the oral cavity, most often through a tooth socket. See also fistula.
fistula, orofacial,
n an opening between the cutaneous surface of the face and the oral cavity.
fistula, oronasal,
n an opening between the nasal cavity and the oral cavity.
fistula, salivary,
n an opening between a salivary duct and/or gland and the cutaneous surface or into the oral cavity through other than the normal anatomic pathway.

fistula

pl. fistulae, fistulas; any abnormal, tubelike passage within body tissue, usually between two internal organs, or leading from an internal organ to the body surface. Some fistulae are created surgically, for diagnostic or therapeutic purposes; others occur as a result of injury or as congenital abnormalities. See also arteriovenous fistula.

blind fistula
one open at one end only, opening on the skin (external blind fistula) or on an internal surface (internal blind fistula).
branchial fistula
a persisting branchial cleft.
complete fistula
one extending from the skin to an internal body cavity.
craniosinus fistula
one between the cerebral space and one of the sinuses, permitting escape of cerebrospinal fluid into the nose.
crop fistula
the crop communicates with the skin on the neck of the bird.
enterocutaneous fistula
one in which there is communication between the intestinal tract and the skin. Some fistulae are created surgically, with gastrostomy, esophagostomy or colostomy. Others may result from surgical trauma, breakdown of an intestinal anastomosis, or erosions around a surgical drain or tube.
esophageal fistula
communication between the esophagus and some portion of the respiratory tract, e.g. trachea, bronchi or pulmonary tissue. May be congenital or acquired as a result of trauma or inflammatory lesions, particularly esophageal foreign bodies.
Enlarge picture
Esophageal fistula. By permission from Knottenbelt DC, Pascoe RR, Diseases and Disorders of the Horse, Saunders, 2003
fecal fistula
a colonic fistula opening on the external surface of the body and discharging feces.
foreign body fistula
remnant of a foreign body impalation or a grass seed are the common causes. Fistula drains continuously.
gastric fistula
an abnormal passage communicating with the stomach; often applied to an artificially created opening, through the abdominal wall, into the stomach.
horseshoe fistula
a semicircular fistulous tract about the anus, with both openings on the skin.
incomplete fistula
blind fistula.
lateral cervical fistula
see branchial cyst.
oroantral fistula
between the oral cavity and a sinus. In dogs, usually involves the maxillary sinus and is caused by periodontal disease of the fourth premolars and first molars.
oronasal fistula
between the nasal and oral cavities. Occurs most commonly in dogs with advanced periodontal disease of the maxillary canine tooth, but can result from disease of canines and premolars. It may also occur after tooth extraction, particularly in dogs, leading to the passage of food into the nasal cavity and a secondary chronic rhinitis and nasal discharge.
ruminal fistula
created surgically in left upper flank. May occur accidentally due to persistence of trocar puncture for treatment of bloat.
salivary fistula
usually discharges saliva on to the side of the face but may discharge into the mouth. Usually due to laceration of the duct by trauma.
umbilical fistula
an abnormal passage communicating with the gut or the urachus at the umbilicus.
urachal fistula
persistence of the urachal canal with communication between the urinary bladder and umbilicus. See also persistent urachus.

Patient discussion about fistula

Q. I developed an AV Fistula after a heart catherization procedure. I am bleeding through the tissues in left arm I am on coumadin, but currently have a lower than usual INR. Corrective surgery was scheduled for yesterday, but had to be delayed. I am concerned that I have a large amount of blood (dark red) bleeding though the tissues right under the skin in my left arm. Should I seek immediate medical attention? The bleeding is over approximately a 3 and 1/2" area on my left arm. Came about in a period of a few minutes.

A. well, you are on blood thinners. i wouldn't take the chance. i mean- i'm not sure i follow what is happening over there. it could be a severe problem or nothing. i would let a doctor check it out. the worse thing that could happen is you wasting a day at the hospital, on the other end of that scenario- you can end up dead. i would go with the first one.

More discussions about fistula