PK ˜€…\_rels/PK ˜€…\ docProps/PK ˜€…\ppt/PK ˜€…\ ppt/_rels/PK ˜€…\ ppt/charts/PK ˜€…\ppt/charts/_rels/PK ˜€…\ppt/embeddings/PK ˜€…\ ppt/media/PK ˜€…\ppt/slideLayouts/PK ˜€…\ppt/slideLayouts/_rels/PK ˜€…\ppt/slideMasters/PK ˜€…\ppt/slideMasters/_rels/PK ˜€…\ ppt/slides/PK ˜€…\ppt/slides/_rels/PK ˜€…\ ppt/theme/PK ˜€…\ppt/notesMasters/PK ˜€…\ppt/notesMasters/_rels/PK ˜€…\ppt/notesSlides/PK ˜€…\ppt/notesSlides/_rels/PK ˜€…\õ‰‰V'$'$[Content_Types].xml PK ˜€…\ðÜÈø]] _rels/.rels PK ˜€…\ŒA4 docProps/app.xml 0 0 Microsoft Office PowerPoint On-screen Show (16:9) 0 17 17 0 0 false Fonts Used 2 Theme 1 Slide Titles 17 Arial Calibri Office Theme Slide 1Slide 2Slide 3Slide 4Slide 5Slide 6Slide 7Slide 8Slide 9Slide 10Slide 11Slide 12Slide 13Slide 14Slide 15Slide 16Slide 17 PptxGenJS false false false 16.0000 PK ˜€…\iüf docProps/core.xml Enterocutaneous Fistula - Surgical Lecture PptxGenJS Presentation Prof. Zahid Mahmood Prof. Zahid Mahmood 1 2026-04-05T16:04:48Z 2026-04-05T16:04:48Z PK ˜€…\–c¢ Í Í ppt/_rels/presentation.xml.rels PK ˜€…\OÝ¨Í Í ppt/theme/theme1.xmlPK ˜€…\ìjí¹¹ppt/presentation.xml PK ˜€…\X›Âppt/presProps.xml PK ˜€…\Øý¶¶ppt/tableStyles.xml PK ˜€…\D >00ppt/viewProps.xml PK ˜€…\H7ût¯¯!ppt/slideLayouts/slideLayout1.xml PK ˜€…\ÕÑ’ñ77,ppt/slideLayouts/_rels/slideLayout1.xml.rels PK ˜€…\ ¬ú1""ppt/slides/slide1.xml Enterocutaneous FistulaA Comprehensive Surgical LectureProf. Zahid MahmoodDepartment of SurgeryFinal Year MBBS | UHS / CPSP Aligned CurriculumBailey & Love Style · Exam-Oriented · Viva Ready · Case-Based LearningPK ˜€…\¯›3öÎÎ ppt/slides/_rels/slide1.xml.rels PK ˜€…\.šš‘ppt/notesSlides/notesSlide1.xml 1PK ˜€…\»:AËË*ppt/notesSlides/_rels/notesSlide1.xml.rels PK ˜€…\Þ­r r ppt/slides/slide2.xml 02Learning Outcomesâ–¶ Define enterocutaneous fistula; classify by output and anatomical siteâ–¶ Enumerate causes; understand pathophysiology and factors preventing healingâ–¶ Recognise clinical features; select appropriate investigations systematicallyâ–¶ Plan conservative and surgical management; list complications and prognosisProf. Zahid Mahmood | Enterocutaneous Fistula | Final Year MBBS | UHS / CPSP CurriculumPK ˜€…\‡2-®ÎÎ ppt/slides/_rels/slide2.xml.rels PK ˜€…\ÙÀ·ppt/notesSlides/notesSlide2.xml 2PK ˜€…\xÕ·ËË*ppt/notesSlides/_rels/notesSlide2.xml.rels PK ˜€…\Ìá6oi i ppt/slides/slide3.xml 03Definitionâ–¶ Abnormal communication between gut lumen and skin surface — ECFâ–¶ Accounts for 75–85% of all gastrointestinal fistulae (Bailey & Love)â–¶ Output defines severity: Low <200 ml/day, Moderate 200–500, High >500 ml/dayâ–¶ High-output ECF carries greatest risk: dehydration, malnutrition, sepsisProf. Zahid Mahmood | Enterocutaneous Fistula | Final Year MBBS | UHS / CPSP CurriculumPK ˜€…\ W/ÎÎ ppt/slides/_rels/slide3.xml.rels PK ˜€…\K |Åppt/notesSlides/notesSlide3.xml 3PK ˜€…\9 YÙËË*ppt/notesSlides/_rels/notesSlide3.xml.rels PK ˜€…\WÈo ppt/slides/slide4.xml 04Classificationâ–¶ By Output: Low (<200 ml/day), Moderate (200–500), High (>500 ml/day)â–¶ By Anatomy: Simple (short, direct tract), Complex (multi-track, abscess, radiation)â–¶ By Aetiology: Spontaneous (Crohn's, TB, malignancy) vs Iatrogenic (post-operative)â–¶ By Location: Duodenal, jejunal, ileal, colonic — determines management complexityProf. Zahid Mahmood | Enterocutaneous Fistula | Final Year MBBS | UHS / CPSP CurriculumPK ˜€…\×`ÎÎ ppt/slides/_rels/slide4.xml.rels PK ˜€…\vsœÿppt/notesSlides/notesSlide4.xml 4PK ˜€…\¿JŒ ËË*ppt/notesSlides/_rels/notesSlide4.xml.rels PK ˜€…\›û˜¨ ¨ ppt/slides/slide5.xml 05Types / Variants — Clinical Relevanceâ–¶ External ECF: Bowel → skin; most common; visible fistula opening on abdominal wallâ–¶ Entero-enteric: Bowel loop to bowel loop; bypass, diarrhoea, malabsorptionâ–¶ Entero-vesical: Bowel to bladder; pneumaturia, faecaluria — diagnostic hallmarkâ–¶ Entero-vaginal: Bowel to vagina; faecal discharge per vaginum; Crohn's / radiotherapyProf. Zahid Mahmood | Enterocutaneous Fistula | Final Year MBBS | UHS / CPSP CurriculumPK ˜€…\ð5ŸÎÎ ppt/slides/_rels/slide5.xml.rels PK ˜€…\ä¸W8ppt/notesSlides/notesSlide5.xml 5PK ˜€…\þQeËË*ppt/notesSlides/_rels/notesSlide5.xml.rels PK ˜€…\]DI´ ´ ppt/slides/slide6.xml 06Etiology / Causes — FRIEND Mnemonicâ–¶ F — Foreign body (mesh, suture); R — Radiation enteritis (delayed effect, ischaemic)â–¶ I — Inflammation/Infection (Crohn's disease, TB, actinomycosis, diverticulitis)â–¶ E — Epithelialisation of tract; N — Neoplasm (primary or secondary bowel tumour)â–¶ D — Distal obstruction; also: Iatrogenic (75–85% post-operative anastomotic leak)Prof. Zahid Mahmood | Enterocutaneous Fistula | Final Year MBBS | UHS / CPSP CurriculumPK ˜€…\ج+ÇÎÎ ppt/slides/_rels/slide6.xml.rels PK ˜€…\âz«ppt/notesSlides/notesSlide6.xml 6PK ˜€…\=|”ÖËË*ppt/notesSlides/_rels/notesSlide6.xml.rels PK ˜€…\U)3¥¢ ¢ ppt/slides/slide7.xml 07Pathophysiology — Why Fistulae Persistâ–¶ Anastomotic breakdown / bowel injury → bowel content leaks into wound/cavityâ–¶ Tract epithelialises → permanent channel forms; spontaneous closure preventedâ–¶ FRIEND factors maintain fistula: distal obstruction, foreign body, malignancyâ–¶ High output → fluid/electrolyte loss → malnutrition → immunosuppression → sepsisProf. Zahid Mahmood | Enterocutaneous Fistula | Final Year MBBS | UHS / CPSP CurriculumPK ˜€…\ÿÉFÎÎ ppt/slides/_rels/slide7.xml.rels PK ˜€…\)±lppt/notesSlides/notesSlide7.xml 7PK ˜€…\|g¸ËË*ppt/notesSlides/_rels/notesSlide7.xml.rels PK ˜€…\Ü:@S¤ ¤ ppt/slides/slide8.xml 08Clinical Features — Signs & Symptomsâ–¶ Wound discharge: enteric content through skin — characteristic presentationâ–¶ Systemic: fever, tachycardia, weight loss, malnutrition — signs of sepsis/catabolismâ–¶ Skin excoriation around fistula opening — from digestive enzymes (esp. proximal ECF)â–¶ High output: dehydration, hyponatraemia, hypokalaemia, metabolic acidosisProf. Zahid Mahmood | Enterocutaneous Fistula | Final Year MBBS | UHS / CPSP CurriculumPK ˜€…\6Â¥ÎÎ ppt/slides/_rels/slide8.xml.rels PK ˜€…\iºÞppt/notesSlides/notesSlide8.xml 8PK ˜€…\p÷O¨ËË*ppt/notesSlides/_rels/notesSlide8.xml.rels PK ˜€…\ÎHη · ppt/slides/slide9.xml 09Investigations — Labs & Imagingâ–¶ Labs: FBC, U&E, LFTs, albumin (<25 g/L = severe malnutrition), CRP, fistula output pHâ–¶ Fistulogram: Water-soluble contrast injected into tract — defines anatomy and courseâ–¶ CT Abdomen + Pelvis: Identifies abscess, distal obstruction, foreign body, malignancyâ–¶ MRI / Barium studies: Delineate complex tracts; assess bowel continuity and diseaseProf. Zahid Mahmood | Enterocutaneous Fistula | Final Year MBBS | UHS / CPSP CurriculumPK ˜€…\§>$ÎÎ ppt/slides/_rels/slide9.xml.rels PK ˜€…\ûÙqppt/notesSlides/notesSlide9.xml 9PK ˜€…\1ìÃÆËË*ppt/notesSlides/_rels/notesSlide9.xml.rels PK ˜€…\ê¬F° ° ppt/slides/slide10.xml 10Management Overview — SNAP Frameworkâ–¶ S — Sepsis control: drain abscess, IV antibiotics, source control — FIRST priorityâ–¶ N — Nutrition: TPN or enteral feeding; restore positive nitrogen balance (albumin >30)â–¶ A — Anatomy: Delineate with fistulogram/CT; identify factors preventing closureâ–¶ P — Plan: Wait 4–6 weeks for spontaneous closure; surgery if FRIEND presentProf. Zahid Mahmood | Enterocutaneous Fistula | Final Year MBBS | UHS / CPSP CurriculumPK ˜€…\çѲºÏÏ!ppt/slides/_rels/slide10.xml.rels PK ˜€…\O¸ý‘‘ ppt/notesSlides/notesSlide10.xml 10PK ˜€…\ÄTœÅÌÌ+ppt/notesSlides/_rels/notesSlide10.xml.rels PK ˜€…\sÛÆ„ „ ppt/slides/slide11.xml 11Conservative Managementâ–¶ NBM + TPN: Bowel rest; high-output ECF requires parenteral nutrition supportâ–¶ Skin care: Stoma bag, barrier creams — protect peri-fistula skin from enzymesâ–¶ Octreotide: Reduces GI secretions; aids closure of high-output fistulaeâ–¶ Spontaneous closure: 30–40% close within 4–6 weeks if no FRIEND factor presentProf. Zahid Mahmood | Enterocutaneous Fistula | Final Year MBBS | UHS / CPSP CurriculumPK ˜€…\À´—;ÏÏ!ppt/slides/_rels/slide11.xml.rels PK ˜€…\Ýs6Ó‘‘ ppt/notesSlides/notesSlide11.xml 11PK ˜€…\…O«ÌÌ+ppt/notesSlides/_rels/notesSlide11.xml.rels PK ˜€…\«K%Û¯ ¯ ppt/slides/slide12.xml 12Surgical Managementâ–¶ Timing: Delay 3–6 months — allow inflammation to settle, optimise nutrition (albumin >30)â–¶ Resection + primary anastomosis: Gold standard; excise fistula tract and diseased bowelâ–¶ Bypass procedure: Proximal stoma; defunctioning if resection high-risk or anatomy complexâ–¶ VSD / NPWT: Negative pressure wound therapy — controls output; aids wound healingProf. Zahid Mahmood | Enterocutaneous Fistula | Final Year MBBS | UHS / CPSP CurriculumPK ˜€…\è‰cÏÏ!ppt/slides/_rels/slide12.xml.rels PK ˜€…\*)@‘‘ ppt/notesSlides/notesSlide12.xml 12PK ˜€…\Fb„ÌÌ+ppt/notesSlides/_rels/notesSlide12.xml.rels PK ˜€…\Ó¯#fº º ppt/slides/slide13.xml 13Complications — Early & Lateâ–¶ Fluid/electrolyte: Severe dehydration, hyponatraemia, hypokalaemia — life-threateningâ–¶ Sepsis: Intra-abdominal abscess, wound infection, bacteraemia → multi-organ failureâ–¶ Malnutrition: Negative nitrogen balance, hypoalbuminaemia → impaired wound healingâ–¶ Late: Persistent/recurrent fistula, skin ulceration, psychological morbidity, mortality 5–20%Prof. Zahid Mahmood | Enterocutaneous Fistula | Final Year MBBS | UHS / CPSP CurriculumPK ˜€…\Ïx¬âÏÏ!ppt/slides/_rels/slide13.xml.rels PK ˜€…\¸âЇ‘‘ ppt/notesSlides/notesSlide13.xml 13PK ˜€…\yvÌÌ+ppt/notesSlides/_rels/notesSlide13.xml.rels PK ˜€…\Ìè4ç ç ppt/slides/slide14.xml 14Mnemonics & High-Yield Exam Pointsâ–¶ FRIEND (causes): Foreign body · Radiation · Inflammation · Epithelialisation · Neoplasm · Distal obstructionâ–¶ SNAP (management): Sepsis · Nutrition · Anatomy · Plan/Procedure — sequence is mandatoryâ–¶ VIVA POINT: Albumin <25 g/L = severe malnutrition; target >30 g/L before surgeryâ–¶ Spontaneous closure unlikely if: high output, short tract, distal obstruction, malignancy, radiationProf. Zahid Mahmood | Enterocutaneous Fistula | Final Year MBBS | UHS / CPSP CurriculumPK ˜€…\¸O´ÓÏÏ!ppt/slides/_rels/slide14.xml.rels PK ˜€…\…š0½‘‘ ppt/notesSlides/notesSlide14.xml 14PK ˜€…\?ݤÌÌ+ppt/notesSlides/_rels/notesSlide14.xml.rels PK ˜€…\‹µzŸ#Ÿ#ppt/slides/slide15.xml Clinical Scenario — Case-Based LearningCASE: A 55-year-old male, 10 days post-elective right hemicolectomy for Crohn's disease, presents with enteric content discharging from a midline wound. Output is 650 ml/day. He is pyrexial (38.4°C), tachycardic, and has lost 4 kg since surgery. Albumin = 20 g/L. CT abdomen shows anastomotic dehiscence with a peri-anastomotic collection.Q1: What is the diagnosis and classification?✔ High-output ECF (>500 ml/day); post-operative (iatrogenic); complex typeQ2: What is the immediate management priority?✔ SNAP: Drain abscess → TPN → Fistulogram → Plan surgery after 3–6 monthsProf. Zahid Mahmood | Enterocutaneous Fistula | Final Year MBBS | UHS / CPSP CurriculumPK ˜€…\Ÿ*‘RÏÏ!ppt/slides/_rels/slide15.xml.rels PK ˜€…\Qûz‘‘ ppt/notesSlides/notesSlide15.xml 15PK ˜€…\À$QÊÌÌ+ppt/notesSlides/_rels/notesSlide15.xml.rels PK ˜€…\Ø˧$6$6ppt/slides/slide16.xml MCQs — SBA Style (CPSP / UHS Pattern)1Q1. Commonest cause of enterocutaneous fistula?A) Crohn's disease B) Radiation C) Post-operative (iatrogenic) ✔ D) Malignancy2Q2. High-output ECF is defined as output greater than?A) 100 ml/day B) 200 ml/day C) 500 ml/day ✔ D) 1000 ml/day3Q3. First priority in management of ECF using the SNAP approach?A) Nutrition B) Surgery C) Sepsis control ✔ D) Anatomy definition4Q4. Which letter in FRIEND mnemonic causes ECF by mechanical interference?A) R (Radiation) B) F (Foreign body) ✔ C) I (Inflammation) D) N (Neoplasm)Prof. Zahid Mahmood | Enterocutaneous Fistula | Final Year MBBS | UHS / CPSP CurriculumPK ˜€…\·ƒ ÏÏ!ppt/slides/_rels/slide16.xml.rels PK ˜€…\à Öé‘‘ ppt/notesSlides/notesSlide16.xml 16PK ˜€…\ ÅyÌÌ+ppt/notesSlides/_rels/notesSlide16.xml.rels PK ˜€…\*„Œ55ppt/slides/slide17.xml High-Yield Summary 1ECF = abnormal bowel-to-skin communication; 75–85% are iatrogenic (post-operative) 2FRIEND causes prevent spontaneous closure — identify and correct before surgery 3SNAP sequence is mandatory: Sepsis → Nutrition → Anatomy → Plan/Procedure 4Surgery delayed 3–6 months; albumin must be >30 g/L; mortality remains 5–20%Prof. Zahid Mahmood | Enterocutaneous Fistula | End of LecturePK ˜€…\檋ÏÏ!ppt/slides/_rels/slide17.xml.rels PK ˜€…\rÀ.‘‘ ppt/notesSlides/notesSlide17.xml 17PK ˜€…\BIÌÌ+ppt/notesSlides/_rels/notesSlide17.xml.rels PK ˜€…\Kà 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