A fistula is an abnormal opening between two hollow organs or between a hollow organ and the skin. Complex medical problems are predisposing factors for fistula formation, such as impaired healing ability after surgery, breakdown of intestinal anastomosis, infection, and Crohn’s disease. In addition, there are challenges associated with fistula management. The fistulas are usually located in areas requiring complex management and containment for patient comfort. These include incisional lines, creases, drainage tubes, or other fistulas. Often the fistula opening is at or below the skin level. As a result, the drainage is eroding, malodorous, and may be of a high volume. High volume fistulas require complex management. This complex management includes multiple supplies used for containment and often requires a letter of medical necessity and detailed chart notes. This blog will discuss nursing care for fistulas between the intestines and the skin.
Classification of Fistula Output
- High volume: greater than 500 milliliters/24 hours
- Moderate volume: 200-500 milliliters per 24 hours
- Low volume: less than 200 milliliters per hour per 24 hours
- Optimize nutritional status
- Monitor fluid and electrolyte balance for high output
- Protect the skin
- Measure and contain the output
- Provide patient comfort
- Manage costs
Low volume fistula output is managed with gauze dressings and skin barrier cream. Larger volumes require applying a pouching system to contain output and protect the skin. Below is a list of supplies you may need to contain fistula output.
- Normal saline for wound cleanser
- A pH-balanced skin cleanser (without moisturizers)
- Stoma powder
- Non-alcohol liquid skin protector/sealants (wipes, sprays, or applicator)
- Non-alcohol stoma paste and strip paste: Think of paste as caulking and not glue. Too much paste can interfere with maintaining a pouch seal.
- Hydrocolloid barrier rings (2” and 4” or squares)
- Ostomy pouch, wound manager pouch, or fistula pouch.
Application of the appliance is time-consuming and requires assistance from another person. Also, plan for appliance change at least an hour after patient oral intake.
- Crusting method: Denuded peri-fistular skin: apply stoma powder, dust off the excess powder, and apply a non-alcohol liquid skin protectant. If using wipes or an applicator, dab on the liquid skin protectant rather than a wiping motion. It may require more than one layer to dry the skin surface.
- Assess for creases to the peri-fistular skin: To maintain a pouch seal, the skin surface must be smooth. Creases can be filled with a thin layer of stoma paste, and hydrocolloid barrier rings broken into strips. Also, the edges of the strips can be smoothed with a thin layer of stoma paste.
- Warming the pouch’s skin barrier helps the adhesive stick better to the skin. Place the pouch under the patient’s under the leg or back with the skin barrier side up.
- Barrier rings provide a good seal around the wound edges and protect the skin. However, you may need to break the ring seal into pieces for large wounds to petal around the wound.
- You may apply a wound manager pouch, fistula manager pouch, a one-piece ostomy pouch, or high output pouch depending on the size of the wound.
- Or uneven skin contours, you may cut darts around the opening of the skin barrier on the pouch and apply a bead of stoma paste over the darts on the skin barrier side.
- Depending on the condition of the peri-fistular skin, it may require more frequent appliance application. After appliance removal, inspect the back of the appliance for any undermining of drainage. The undermining of effluent will indicate any you may need to fill in with accessory products.
- Have the patient stay supine 20-30 minutes after appliance application to allow products to set up and provide a better seal.
High output fistulas require complex and time-consuming management of care. It is important to provide patient comfort by maintaining an appliance seal. The maintenance can also be costly due to the number of supplies required. Managing costs by providing detailed notes and a letter of medical necessity to help cover the cost of supplies.
The views and opinions stated in this blog are exclusively those of the author and do not reflect iWound, its affiliates, or partner companies.
Future Reading and References
Ashkenazi, I., Turégano-Fuentes, F., Olsha, O., & Alfici, R. (2017). Treatment Options in Gastrointestinal Cutaneous Fistulas. Surgery journal (New York, N.Y.), 3(1), e25–e31. https://doi.org/10.1055/s-0037-1599273
Brooke, Jillian; El-Ghaname, Amanda; Napier, Karen; Sommerey, Laureen Executive Summary: Nurses Specialized in Wound, Ostomy and Continence Canada (NSWOCC) Nursing Best Practice Recommendations, Journal of Wound, Ostomy and Continence Nursing: July/August 2019 – Volume 46 – Issue 4 – p 306-308
Gribovskaja-Rupp, I., & Melton, G. B. (2016). Enterocutaneous Fistula: Proven Strategies and Updates. Clinics in colon and rectal surgery, 29(2), 130–137. https://doi.org/10.1055/s-0036-1580732
Jerez González, José Antonio; Quiñones Sánchez, Cristina; Márquez Rodríguez, Francisca Catastrophic Abdominal Wall After Repair of Enterocutaneous Fistula, Journal of Wound, Ostomy and Continence Nursing: July/August 2019 – Volume 46 – Issue 4 – p 337-342 doi: 10.1097/WON.0000000000000539
Michel, Marie RN, CWCA, CHRN, OMS; Sherfey, Sally RN, CWCA Creativity in Containing a Patient’s High-Output Fistula: A Case Report, Advances in Skin & Wound Care: October 2020 – Volume 33 – Issue 10 – p 1-3 doi: 10.1097/01.ASW.0000695760.91321.32
Reider, Kersten E. Fistula Isolation and the Use of Negative Pressure to Promote Wound Healing, Journal of Wound, Ostomy and Continence Nursing: May/June 2017 – Volume 44 – Issue 3 – p 293-298 doi: 10.1097/WON.0000000000000329
Wright H, Kearney S, Zhou K, Woo K. Topical Management of Enterocutaneous and Enteroatmospheric Fistulas: A Systematic Review. Wound Manag Prev. 2020 Apr;66(4):26-37. doi: 10.25270/wmp.2020.4.2637. PMID: 32294057.
Yang, Hui MM; Rui, Yuanyi MD; Chen, Hong MD Management of a Pelvic Abscess and Abdominal Fistula after Palliative Total Pelvic Exenteration with Intraoperative Radiotherapy in Recurrent Rectal Cancer Without NPWT: A Case Report, Advances in Skin & Wound Care: December 2021 – Volume 34 – Issue 12 – p 675-679 doi: 10.1097/01.ASW.0000797964.31949.b4
Zhu, Li-Bo; Sun, Jia-nan; Cong, Yue; Wang, Ting; Hu, Jieman; Hu, Hai-yan Management of a Complex Peristomal Fistula, Journal of Wound, Ostomy and Continence Nursing: January/February 2021 – Volume 48 – Issue 1 – p 76-78 doi: 10.1097/WON.0000000000000729