Nutritional management of gastroenterocutaneous fistulas

Despite significant improvements in medical and surgical treatments of gastroenterocutaneous fistulas (ECFs), they remain a significant cause of morbidity and mortality for patients who develop them. A hypermetabolic response and profound disturbances in fluid and electrolyte levels, leading to dehydration, hyponatraemia, hypokalemia, and metabolic acidosis, are common, making this patient population a unique subgroup of critically ill patients vulnerable to further decline in nutritional status. In general, medical treatment and stabilization precede attempts at surgical intervention and remain a hallmark of therapy for ECFs. The most challenging aspect of ECF management is nutritional repletion because there is no standard protocol, and each patient and case is unique. The management requires patient- as well as fistula-specific factors to be considered for optimizing the best treatment regimen. Currently, there are no well-established, evidence-based clinical guidelines for managing the medications and nutrition care of these patients. Although it is often difficult and sometimes impossible to provide adequate enteral nutrition in the presences of an ECF, nutritional support should be implemented whenever possible. Many questions have been answered; however, there is no uniformity to these answers. This chapter reviews the roles of enteral and supplemental parenteral nutrition, somatostatin, and immune-modulating nutritional supplementation.