1. Stomas and fistulas القاء : مصعب شومان محمد الصافي محمد البدري عبدالسلام البوريني سيرينا ربابعة عروبة طلاس

2. Ostomy Vs fistula ?  Both are :Communication betw two epithelial cell layers  So wt is the diff?  Stoma?  Sinus?

4. The same wound 3 weeks later. The sinus has opened widely to reveal its cause – an infected arterial graft. A discharging sinus from the centre of a groin wound.

5. “ ” Stomas

6.  Calssification: 1-permanent /temporary 2- End stoma?/loop stoma?/double barrel?  Hartman ? Urostomy?  Why (indications )?

7. stomas Note : stomas are usually implanted in the rectus sheath to prevent parastomal hernia

8. Stomas

11. vs

12. Stomas hartman

13. Stomas

14.  Examples : 1. Gastrostomy 2. Jejunostomy 3. Colostomy 4. Iliostomy …etc

16. COMPLICATIONS

17. Stomas 1- systemic : sepsis,metabolic :electrolytes imbalnces,dehydration 2- Local  Poor siting - Poor siting is when the stoma has been created in a site that makes it impossible for the patient to manage the stoma. This can range from an inability to change the stoma, dermatitis due to leakage of the effluent to the stoma being difficult to conceal. It is essential that stomas are sited in areas of the body away from bone, old scars or the umbilicus.  Stoma proper - This involves problems with the stoma itself and include necrosis, retraction, prolapse, bleeding and luminal stenosis, functional disorders such as diarrhoea and constipation.  Peri-intestinal area - Complications at the peri-intestinal area is a parastomal hernia. Loops of intestine protrude through the opening into the subcutaneous tissue around the stoma. It is a late complication and can be due to poor surgical technique or a gradual enlargement of the fascial defect.  Mucocutaneous junction - separation of the stoma from the peri-stomal skin. This manifests initially as erythema and can be a complication of poor surgery or secondary to retraction or necrosis. It is common in the immunocompromised state such as patients receiving steriods, diabetics and the malnourished patient.  Iatrogenic - Iatrogenic complications include belts that rub the stoma, razors when shaving peri- stomal skin. Injury to stomas often goes unnoticed as stomal mucosa has no nerve endings.

18. Stomas  It is the death of stomal tissue resulting from impaired blood flow.  Ischemia typically occurs within 24 hours of the ostomy surgery, resulting in a dark, necrotic stoma that appears maroon to black and is typically soft and flabby to palpation. Mostly due to :  mesenteric tension.  clipping of the mesentery. Stomal necrosis

19. Stomas -Defined as: the disappearance of normal stomal protrusion in line with or below the skin level. -Common causes: include problems with surgical construction of the ostomy resulting in mesenteric tension or an inadequate stomal length. Stomal retraction

20. Stomas  Stomal stenosis: is defined as impairment of effluent drainage due to narrowing or contraction of the stomal tissue at the level of the skin or fascia.  Parastomal hernia:

21. Stomas Defined as: a telescoping of intestine through the stoma.  It is particularly prevalent in loop transverse colostomies Stomal prolapse

22. Stomas

24. Physical Examination INITIALY Wash hands and ensure privacy Introduce yourself and confirm patient's identity Explain procedure and obtain consent Expose abdomen fully Reposition patient lying down / 45 GENERALY Around the patient The patient as a whole Hands Mucus mem. in eyes and mouth Abdomen / stoma Inspection location (RIF/LIF/RUQ) Stoma bag contents Relation to skin If it is with one or two lumens (type) Ask the pt to cough (parastomal hernia) Skin around the stoma ! Palpation Around the stoma Insert your finger inside the stoma Auscultation of bowel sounds

25. To finish the examination: Do a full abdominal examination Do a rectal examination Assess the patient's fluid status Inspect the patient's drug chart for medications to increase/reduce stoma output, and electrolyte supplements (in cases of high output stomas) Thank the patient and offer help to get dressed.

26. Stomas  Ileostomy vs colostomy ? colostomyIliostomy LIF( loop colostomy in RUQ )RIF location( usually ) FlatspoutRelation to skin Intermittent,solid,odor(like stool) continuous, Higher volume of fluid Output

27. Stomas

31. Fistula OBJECTIVES: 1) DEFINITION. 2) TYPES & CAUSES OF FISTULAS. 3) EXAMPLES OF FISTULA. 4) COMPLICATIONS.

32. Definition Fistula: is an abnormal communication between two epithelium lined surfaces, this communication or tract may be lined by granulation tissue but may become epithelialized in chronic cases. - Fistula can arise in any part of the body, but they are most common is the digestive tract. - They can also develop between blood vessels and in the urinary, reproductive and lymphatic systems.

33. Fistula….  - Fistulas can occur: . 1- at any age or  2- can be present at birth (congenital).  - Some are life threatening, others cause discomfort, while still are benign and go undetected or cause few symptoms

34. *Fistulas are categorized by: 1.the number of openings they have and 2. whether they connect two internal organs or open through the skin. * There are three types: 1. Blind fistula. 2. Complete fistula. 3. Incomplete fistula.

35. 1) Blind fistulas: - an abnormal passage which opens at one end only and creates a pocket. - The openings may be: a. on the body surface or b. or within an internal organ or structure. - Sinus : A tract or fistula leading to a cavity which may be filled with pus, so sinus is a blind fistula. 2) Complete fistulas: - an abnormal passage from an internal organ or structure to the surface of the body or to another internal organ or structure  two openings.

36. 3) Incomplete fistula: - is a fistula with an external skin opening only, which does not connect to any internal organ.

37. Causes of surgical fistulas (most common): Lysis of adhesions Bowel resection for IBD Bowel resection for cancer Surgery for pancreatitis Surgery on radiated bowel

38. Causes of spontaneous fistulas : Radiation Inflammatory bowel disease Diverticular disease Appendicitis Ischemic bowel Perforation of duodenal ulcers Pancreatic and gynecologic malignancies Intra-abdominal abscesses Abdominal penetrating trauma

39. Examples: ♦ Anal or ‘perianal’ fistulas. the most common form of fistula. ♦ Bowel to BLADDAR fistulas. ♦ Bowel to VAGINA or enterovaginal fistulas. If the fistula links the rectum to the vagina it is known as a rectovaginal fistula. ♦ Bowel to SKIN fistulas.

40. Complications of Fistulas 1. Fluid and electrolyte imbalances 2. Sepsis 3. Skin excoriation 4. Malnutrition 5. Hemorrhage 6. Infections

41. 1- Fluid and electrolyte imbalances:  Are frequent complications of fistulas, especially those involving the proximal bowel or pancreas.  Electrolyte losses can be directly measured from a sample of the fistula drainage. For example, a pancreatic fistula that drains 700 mL of bicarbonate-rich fluid a day can produce dehydration and metabolic acidosis.

42. 2- Sepsis:  Occurs when the contents of an organ leak and contaminate sterile spaces (e.g. peritoneum or pleura).

43. 3- Skin Excoriation:  Can occur when intestinal secretions drain into the skin.  The drainage from enterocutaneous fistulas irritate the skin.  This can be painful and result in cellulitis or sepsis.

44. 4- Malnutrition:  1- Can develop either from inadequate absorption of nutrients DUE TO: ----Short circuiting of the bowel (gastrocolic fistula ) ----External loss of ingested food (high-output enterocutaneous fistula)  2- Because of increased caloric needs from associated infection or stress.

45. 5- Hemorrhage:  Is an infrequent but potentially life-threatening complication of enteric fistulas.  It occurs when a fistula erodes into a mesenteric blood vessel, causing severe bleeding.

46. 6- Infections:  Enterovesicular fistulas often cause recurrent urinary tract infections.

48. Esp. EC fistula Fistula/7

49.  causes of failure of conservative management: Fistula/8 +High output(>500cc) and Short fistula(<2.5cm)