A 65-year-old normally built gentleman presented to the outpatient with sudden onset discharge of faecal contents from an opening in the left inguinal region. The oral intake was adequate and he was passing stools and urine normally. There was no history suggestive of diabetes mellitus, tuberculosis or Crohn's disease. It started as a red, painful swelling in the inguinal region three days back, which ruptured spontaneously discharging faecal contents. Patient had undergone total penectomy with bilateral orchiectomy and perineal urethrostomy, 27 years earlier for carcinoma of the penis, followed by 60 Gy adjuvant external beam radiotherapy (EBRT) to the pelvis and para aortic nodes in 30 fractions. He was on a regular follow-up except for the last five years when he was lost to follow-up.
Examination revealed a well preserved; 140 lbs man (height 165 cm) with no features of anemia, hypoproteinemia, dehydration or electrolyte disturbances. His performance status was good and nutrition risk index (NRI) was >90 (NRI = 1.519 x Serum albumin (g/l) + 0.417 x (current wt/usual wt) x 100). Based on subjective global assessment (SGA) (including clinical criteria like weight loss in previous six months, recent dietary intake compared to the usual intake, presence of anorexia etc.) and Eastern Cooperative Oncology Group (ECOG) criteria his performance and nutritional status was good. Abdomen was scaphoid with no organomegaly or any lymphadenopathy.
There was a discharging fistulous opening in the left ilio-inguinal area approximately 5 cm from the pubic symphysis (figure 1). The discharge was faecal with no evidence of pus in it. The routine investigations including the blood biochemistry were normal. Abdominal ultrasound was normal. Contrast enhanced computed tomography (CECT) abdomen (figure 2) revealed an enterocutaneous fistula and there was no evidence of any recurrent or remnant disease. Fistulogram (figure 3) confirmed the communication with the small bowel. Since the patient was well preserved, with good performance and nutritional status, with adequate oral intake, features of intestinal obstruction, evidence of any underlying malignancy and it being a low output fistula (with a daily out put less than 100 ml), he was managed conservatively on expectant treatment.
The general management included replenishment of fluid and electrolyte losses, and nutritional supplements. The local skin care involved using skin protective emollients creams (containing dimethicone 20%, zinc oxide 7.5%, calamine 1.5% and cetrimide 1.125%) and egg white around the fistula site to protect the skin. An ileostomy bag was fitted in order to allow the fistula to close spontaneously and to measure the output in 24 hours accurately. The daily intake and output chart was maintained to accurately assess the loss for replacement. He made a satisfactory recovery with the output gradually reducing to less than 5 ml and was discharged on the tenth day. Patient has made a satisfactory recovery and now has completed three years on follow-up.