Hepatic Failure/GI/Endocrine Emergencies

Somatostatin significantly reduces output volumes. One prospective, randomized controlled

single-center trial compared somatostatin 250 mcg/hour intravenously continuously with placebo

for patients receiving TPN. Somatostatin significantly reduced the time to achieve a 50%, 75%, and

100% reduction in fistula output compared with placebo; also, although there was no difference in

the rates of fistula closure (85% vs. 81.25%), the time to fistula closure was significantly reduced

with the use of somatostatin (13.9 days vs. 20.4 days, p<0.05).

no effect on fistula output.

One small study of 14 patients showed a beneficial effect of octreotide on output volumes.

In this crossover study, octreotide at 100 mcg subcutaneously three times daily significantly

reduced fistula output compared with placebo for the first 2 days of therapy by about 400 mL/

day. When the group that was originally randomized to receive octreotide crossed over to the

placebo arm, output increased by about 250 mL/day.

ii.

Two subsequent studies did not show similar results on fistula output. Possible reasons for

decreased efficacy with octreotide include diminished response with repeat dosing and

decreased activity at some somatostatin receptors.

Reduction in fistula output with the use of somatostatin or octreotide should occur within 48 hours.

If no noticeable response in fistula response occurs at 48 hours, treatment should be discontinued.

Refractory high-output fistula management

Acid-suppressing medications (e.g., PPIs and histamine-2 receptor antagonists) have been studied

for the treatment of refractory fistula because of their ability to decrease gastric acidity and decrease

the amount of gastric secretions. Proton pump inhibitors are more effective than histamine-2

receptor antagonists for refractory fistula output.

Antimotility agents are usually recommended (e.g., loperamide, diphenoxylate/atropine, codeine)

because of their ability to inhibit the activity of gastrointestinal tract muscles.

Loperamide has the greatest effect on fistula output. In studies, loperamide doses up to 12–24

mg per dose have been given safely for the management of high-output fistulas. However, due

to concerns for adverse reactions, caution should be advised with doses higher than 16 mg

per day. Additionally, administration of large quantities of the liquid form of loperamide may

increase fistula output.

Conservative versus surgical management

Conservative management is first line for most patients, with the primary goal being spontaneous

closure of the fistula. Several prognostic indicators improve the likelihood of spontaneous closure.

Low-output fistulas

ii.

Patients younger than 40 years

iii.

Fistula sites: Oropharyngeal, esophageal, duodenal, pancreatic, jejunal

iv.

A long fistula tract (greater than 2 cm)

Intestinal continuity maintained

Surgery is usually indicated for fistulas that fail to close spontaneously after 30–60 days. Some

causes of fistula formation (e.g., bowel injury caused by trauma or certain surgical procedures) may

require emergency surgery to repair damage.