Small bowel fistulas

Most external small bowel fistulas follow surgical operation, but a few develop spontaneously. Seventy percent will close with conservative treatment including vigorous nutritional support and elimination of sepsis. Internal fistulas involving the small bowel always result from extension of disease in the bowel or in adjacent viscera, and they virtually never close spontaneously. Our 11‐year experience of 71 Crohn's fistulas confirms 2 types. Type 1 (n=49) results from spontaneous extension of active bowel disease, while type 2 (n=22) follows leakage of an anastomosis. The former virtually always requires surgical closure, which can usually be achieved without mortality and with minimal complications. Most type 2 fistulas will close with parenteral nutrition, but staged surgery with exteriorization of bowel ends may be required. Our 4 deaths were all among type 2 cases. High‐output fistulas with severe associated sepsis should be managed in specialized intestinal failure units. In just under 4 years, 51 patients with complicated intestinal fistulas have been treated in this department, with a 23.5% mortality rate.