Dr. Schoenfield served as associate professor of medicine and consultant in gastroenterology on the faculty of the Mayo Clinic for seven years. He became a professor of medicine in residence at UCLA from 1972 to 1999 (now emeritus). He was the director of gastroenterology at Cedars-Sinai Medical Center in Los Angeles for 25 years, where he received the chief resident's teaching award, the president's award, and the pioneer of medicine award.
Intestinal fistulas are tubular connections between the bowel and other
organs or the skin. Fistulas form when inflammation extends through all of the
layers of the bowel and then proceeds to tunnel through the layers of other
tissues. Accordingly, fistulas are much more common in Crohn's disease than in
ulcerative colitis. (In the
latter, as you recall, the inflammation is confined to the inner lining of the
large intestine.) Fistulas often are multiple. They may connect the bowel to
other loops of the bowel (enteroenteric fistulas), to the abdominal wall (enterocutaneous),
to the skin around the anus (perianal), and to other internal locations such as
the urinary bladder (enterovesical), vagina (enterovaginal), muscles, and
scrotum.
In Crohn's disease patients, fistulas may form in conjunction with intestinal
strictures. One reason for this association is that both fistulas and strictures
can begin with inflammation of the entire thickness of the bowel wall (transmural
inflammation). Subsequent scarring (fibrosis) causes strictures while continuing
inflammation and tissue destruction leads to the fistulas. A stricture can also
help create a fistula. As already mentioned, a perforation of the intestine can
occur above an obstructing stricture. The perforation can create a tract outside
of the bowel wall. A fistula then may develop in this tract.
What symptoms do fistulas cause and how are they diagnosed and treated?
Intestinal fistula symptoms
Some fistulas, especially those that connect adjacent loops of bowel, may not
cause significant symptoms. Other fistulas, however, can cause significant
abdominal pain and external drainage, or create a bypass of a large segment of
intestine. Such a bypass can occur when a fistula connects one part of the bowel
to another part that is further down the intestinal tract. The fistula thereby
creates a new route for the intestinal contents. This new route bypasses the
segment of intestine between the fistula's upper and lower connections to the
intestine. Sometimes, fistulas can open and close sporadically and unevenly.
Thus, for example, the outside of a fistula might heal before the inside of the
fistula. Should this occur, the bowel contents can accumulate in the fistulous
tract and result in a pocket of infection and pus (abscess). An abscess may be
quite painful and can be dangerous, especially if the infection spreads to the
bloodstream.
Intestinal fistula diagnosis
Fistulas sometimes are difficult to detect. Although the outside
opening of a fistula may be simple to see, the inside opening that is connected
to the bowel may not be easy to locate. The reason for this difficulty is that
fistulas from the bowel can have long, winding tunnels that finally lead to the
skin or an internal organ. Endoscopy might detect the internal opening of a
fistula, but it can easily be missed. Sometimes, a small bowel barium X-ray will
locate a fistula. Often, however, an exam under general anesthesia may be
required to fully examine areas that have fistulas, especially around the anus
and vagina.
Intestinal fistula treatment
Intestinal fistulas that do not cause symptoms often require no treatment.
Fistulas that cause significant symptoms, however, usually require treatment,
although they are frequently difficult to heal.
Fistulas located around the anus
(perianal) sometimes can be improved by treatment with the antibiotics,
metronidazole (Flagyl) or ciprofloxacin (Cipro). In response to the antibiotics,
some of these fistulas even close completely. Also, treatment with the
immunosuppressive medications, azathioprine or 6MP, improves fistulas located
around the anus (perianal) in almost two thirds of patients, including complete
healing in one third. More recently, the new drug infliximab (Remicade), which
is an antibody to one of the body's inflammation-inducing chemicals, has been
shown to produce very similar results. Remember, however, that infliximab might
worsen strictures, which, as mentioned, can sometimes be associated with
fistulas.
When medications for the treatment of fistulas are discontinued, they
usually re-open within 6 months to a year. Steroids do not heal fistulas and
should not be used for this purpose. Other medications that suppress the immune
system, such as cyclosporine or tacrolimus (FK506 or Prograf), are currently
being studied for the treatment of fistulas. Sometimes, resting the bowel by
feeding the patient solely with total parenteral (intravenous) nutrition (TPN),
is required to treat fistulas. Even if these fistulas heal in response to the
TPN, they commonly recur when eating is resumed.
Fistulas sometimes require
surgery. For example, when fistulas around the anus become very severe, they can
interfere with the patient's ability to control bowel movements (continence). In
this situation, the surgeon might make an opening (ostomy) to the skin from the
bowel above the fistulas. The intestinal contents are thereby diverted away from
the fistulas. Occasionally, when absolutely necessary, intestinal fistulas are
surgically removed, usually along with the involved segment of the bowel.
Fistulas from the intestine to the bladder or vagina are frequently very
difficult to close with medical treatment alone and often require surgery.
Abdominal pain is pain in the belly and can be acute or chronic. Causes include inflammation, distention of an organ, and loss of the blood supply to an organ. Abdominal pain can reflect a major problem with one of the organs in the abdomen such as the appendix, gallbladder, large and small intestine, pancreas, liver, colon, duodenum, and spleen.
Anemia is the condition of having less than the normal number of red blood cells or less than the normal quantity of hemoglobin in the blood. The oxygen-carrying capacity of the blood is, therefore, decreased.
Rectal bleeding (hematochezia) refers to the passage of bright red blood from the anus. Rectal bleeding may be moderate to severe and most bleeding comes from the colon, rectum, or anus. Common causes include anal fissures, hemorrhoids, diverticulitis, and more.
One in every 20 people develop a kidney stone at some point in their life. A kidney stone is a hard mineral and crystalline material formed within the kidney or urinary tract. Kidney stones symptoms and signs are, blood in the urine and pain in the abdomen, flank (lower back), or groin. A number of different conditions can lead to kidney stones including: gout, hypercalciuria, people with inflammatory bowel disease, kidney disease, and hypoparathyroidism. Some medications also increase the risk of kidney stones.
Crohn's disease is a chronic inflammatory disease,
primarily involving the small and large intestine, but which can
affect other parts of the digestive system as well. Abdominal pain, diarrhea, vomiting, fever, and weight loss are
common symptoms.
Pink eye, also called conjunctivitis, is redness or irritation of the conjunctivae, the membranes on the inner part of the eyelids and the membranes covering the whites of the eyes. These membranes react to a wide range of bacteria, viruses, allergy-provoking agents, irritants, and toxic agents.
Diarrhea is a change is the frequency and looseness of bowel movements. Cramping, abdominal pain, and the sensation of rectal urgency are all symptoms of diarrhea. Absorbents and anti-motility medications are used to treat diarrhea.
Colon cancer is a malignancy that arises from the inner lining of the colon. Most, if not all, of these cancers develop from colonic polyps. Removal of these precancerous polyps can prevent colon cancer.
Liver disease can be cause by a variety of things including infection (hepatitis), diseases such as gallstones, high cholesterol or triglycerides, blood flow obstruction to the liver, and toxins (medications and chemicals). Symptoms of liver disease depends upon the cause; however, common symptoms may include nausea, vomiting, upper right abdominal pain, and jaundice. Treatment depends upon the cause of the liver disease.
Ulcerative colitis is a chronic inflammation of the colon. Symptoms include abdominal pain, diarrhea, and rectal bleeding. Ulcerative colitis is closely related to Crohn's disease, and together they are referred to as inflammatory bowel disease. Treatment depends upon the type of ulcerative colitis diagnosed.
Pernicious anemia is a blood disorder in which the body does not make enough red blood cells due to a lack of vitamin B12 in the blood. Pernicious anemia can develop from a lack of a protein that helps the body absorb vitamin B12, not getting enough B12 in the diet, and certain intestinal conditions that interfere with the absorption of vitamin B12 such as Crohn's disease, celiac sprue, or ulcerative colitis. There is no cure for pernicious anemia, thus treatment is life-long.
Inflammation of the inner lining of the colon is referred to as colitis. Symptoms of the inflammation of the colon lining include diarrhea, pain, and blood in the stool. There are several causes of colitis including infection, ischemia of the colon, inflammatory bowel disease (Crohn's disease, Ulcerative colitis, or microscopic colitis). Treatment depends on the cause of the colitis.
Juvenile arthritis (juvenile rheumatoid arthritis or JRA) annually affects one child in every thousand. There are three types of JRA: pauciarticular (less than four joints affected), polyarticular (more than four joints affected), and systemic-onset (inflamed joints with high fevers and rash). Treatment of juvenile arthritis depends upon the type the child has and should focus on treating the symptoms that manifest.
Corticosteroid drugs such as prednisone and prednisolone are commonly used to treat asthma, allergic reactions, RA, and IBD. Steroids such as these do have serious drawbacks such as steroid withdrawal symptoms such as: fatigue, weakness, decreased appetite, weight loss, nausea, vomiting, abdominal pain, and diarrhea. Speak with your healthcare provider prior to tapering off steroid medications.
Shigellosis is a disease caused by the Shigella bacteria. Bloody diarrhea, stomach cramps and fever are common symptoms. Mild infections usually resolve on their own. Antibiotics are used to treat more severe cases.
Bronchiectasis is a condition in which the bronchial tubes of the lung become damaged. Inflammation from infection or other causes destroys the smooth muscles of the bronchial tubes. Bronchiectasis is a form of COPD (which includes emphysema and chronic bronchitis). There are three primary types of bronchiectasis: 1) cylindrical bronchiectasis; 2) saccular bronchiectasis; and 3) cystic bronchiectasis. Bronchiectasis may also be acquired or congenital. The most common symptoms of bronchiectasis are recurrent cough and sputum production. There is no cure for bronchiectasis. Treatment is often geared toward controlling the symptoms of bronchiectasis.
Abdominal adhesions (scar tissue) bands of scar tissue that form between abdominal organs and tissues. Symptoms of abdominal adhesions are pelvic or abdominal pain. Abdominal adhesions on the intestines can cause bowel obstruction, which is a medical emergency. Treatment for abdominal adhesions is generally surgery to cut the adhesions away from the internal tissues and organs. There is no way to prevent abdominal adhesions.
Brain lesions (lesions on the brain) are caused by trauma, inflammation, autoimmune diseases, cancers, other diseases, stroke, bleeding, pituitary adenomas, and cerebral palsy. Symptoms of brain lesions include headache, nausea, fever, neck pain and stiffness, affected vision and speech, weakness or paralysis to one side of the body. Diagnosis of brain lesions is generally with imaging studies like CT or MRI scans. Treatment and prognosis of brain lesions depends on the cause of the lesion.
Scleritis is inflammation of the white part of the eye. It may be caused by a serious underlying condition, such as an autoimmune disease. Symptoms include redness, pain, tearing, sensitivity to light, and decreased visual acuity. Treatment may include eye drops as well as treatment for any underlying disease process. Scleritis cannot be prevented.
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