Case History:
My mother was admitted to the hospital with acute pain in the
abdominal. She is 60 years old. After conducting the diagnositc tests,
Doctors have confimed that it was Ruptured Appendicitis.  Surgeons
have perfomed the Appendectomy to remove the Appendix. A tube was
inserted for draining the abscess.

After 2 weeks, the fecal matter is discharging into the abdomin. An
incision was made in the skin to drain out the fecal matter. A bag was
attached to collect the continuous leakage of fecal matter. However,
the patient is also passing the normal bowel movement through rectum.
The patient is suffering severe pain where there is a discharge of
fecal matter from the abdomin skin.
The amount of discharge into the bag varies from time to time. If the
patint passes the normal bowel through the rectum then the quantiy of
fecal matter in the bag will be less. Otherwise, the qantitiy will be
more.
Patient has a history of Diabetes and Blood Pressure. But both
diseases are under control using medications.

Patient has been giving pain medicaions, anti-biotics and insulin. The
temperature of patient is normal. Some times in the night it slightly
increases but it will come back to normal. Urine tests indicate
negative ketones.

30 days have passed from the date of surgery. The patient is still
suffering from the pain at the abdomin where the Fecal Matter is
discharging.

Question: 
1). What is the Solution for this problem?
2). How long will it take to heal?
3). Do we have to conduct any additional tests?
4). What precautions has to take?

Hi youngerson,

Let me start off with, I am sorry you and your
family are having this situation.

Secondly... I would like to state that Google
Answers is a resource of information and should
not be used as a "second opinion". Considering
that medicine is being "practiced", the information
that is contained herein should not be considered
absolute. Qualified examination is required for an
accurate diagnosis.


Before I begin. I surely hope this postoperative
care is being performed in the hospital?

If this is in a hospital, why have they allowed
it to go on this long? Everything I have read
about her current condition seems to indicate
it is a dire situation. From what I have gathered
it appears that the surgery was not successful.
What started as an appendicitis and progressed to
a ruptured appendicitis appears to have now
become Abdominal Sepsis or Peritonitis.

What follows is alot of text from emedicine.com.
I have found that their information is very in
depth and thorough. You can jump to the bottom
for the summary of answers to your questions 1-4.

-=-=-=-=-=-=-=-=-=-=-=-

"Peritonitis and Abdominal Sepsis
Author: Thomas Genuit, MD, Assistant Professor, Department
of Surgery, Program in Trauma and Surgical Critical Care,
University of Maryland School of Medicine
Coauthor(s): Lena Napolitano, MD, Vice-Chair, Department of
Surgery, VA Maryland Healthcare System; Professor,
Department of Surgery, University of Maryland School of
Medicine
     on emedicine.com
[ http://www.emedicine.com/med/topic2737.htm ]
"Peritonitis is defined as inflammation of the serosal
membrane that lines the abdominal cavity and the organs
contained therein. Peritonitis is often caused by
introduction of an infection into the otherwise sterile
peritoneal environment through perforation of the bowel,
such as a ruptured appendix."

-=-=-=-=-=-=-=-=-=-=-=-

"Peritoneal infections are classified as primary (ie,
spontaneous), secondary (ie, related to a pathologic
process in a visceral organ), or tertiary (ie, persistent
or recurrent infection after adequate initial therapy). The
intra-abdominal infection may be localized or generalized,
with or without abscess formation."

-=-=-=-=-=-=-=-=-=-=-=-

"The spectrum of pathogens depends to some degree on the
site of the original disease. Gram-positive organisms
predominate in the upper GI tract; however, a shift toward
gram-negative organisms may be noticed in patients on
long-term gastric acid suppressive therapy. Contamination
from a distal small bowel or colon source initially may
result in the release of several hundred bacterial species
(and fungi); host defenses quickly eliminate most of these
organisms. The resulting peritonitis is almost always
polymicrobial, containing a mixture of aerobic and
anaerobic bacteria with a predominance of gram-negative
organisms."

-=-=-=-=-=-=-=-=-=-=-=-

"In general, the incidence of abscess formation after
abdominal surgery is less than 1-2%, even when the
operation is performed for an acute inflammatory process.
This incidence increases with preoperative perforation of
the hollow viscus, significant fecal contamination of the
peritoneal cavity, bowel ischemia, delayed diagnosis and
therapy of the initial peritonitis, the need for
reoperation, and in the setting of immunosuppression. In
these instances, the risk of abscess formation may be as
high as 10-30% (Reid, 1999). Overall, abscess formation is
the leading cause of persistent infection and development
of tertiary peritonitis.

"Tertiary peritonitis represents the persistence or
recurrence of peritoneal infection following apparently
adequate therapy of SBP or SP, often without the original
visceral organ pathology. Patients with tertiary
peritonitis usually present with an abscess, or phlegmon,
with or without fistulization. Tertiary peritonitis
develops more frequently in patients with significant
preexisting comorbid conditions and in patients who are
immunocompromised. Although rarely observed in
uncomplicated peritoneal infections, the incidence of
tertiary peritonitis in patients requiring ICU admission
for severe abdominal infections may be as high as 50-74%.

"Patients who develop tertiary peritonitis demonstrate
significantly longer lengths of stay in the ICU and
hospital, higher organ dysfunction scores, and higher
mortality rates (50-70%). Resistant and unusual organisms
(eg, Enterococcus, Candida, Staphylococcus, Enterobacter,
and Pseudomonas species) are found in a significant
proportion of cases of tertiary peritonitis. Most patients
with tertiary peritonitis develop complex abscesses or
poorly localized peritoneal infections that are not
amenable to percutaneous drainage. Antibiotic therapy
appears less effective compared to all other forms of
peritonitis (Nathens, 1998)."

-=-=-=-=-=-=-=-=-=-=-=-

"Early control of the septic source is mandatory and can be
achieved by operative and nonoperative means. Nonoperative
interventional therapies include percutaneous drainage of
abscesses and percutaneous and endoscopic stent placements.
If an abscess is accessible to percutaneous drainage and
the underlying visceral organ pathology does not clearly
require an operative approach, percutaneous drainage can be
used safely and effectively as the primary treatment
modality (Levison, 1992; Hemming, 1991; Rothlin, 1998).

"Operative management addresses the need to control the
infectious source and to purge bacteria and toxins. The
type and extent of surgery depends on the underlying
disease process and the severity of intra-abdominal
infection (Wittmann, 1998). Open treatment allows for
thorough drainage of the intra-abdominal infection, but the
specific indications are not clearly defined."

-=-=-=-=-=-=-=-=-=-=-=-

"Lab Studies:

"In general, perform a complete blood cell (CBC) count with
differential in patients who present with peritoneal
infections and evaluate the serum electrolyte panel with
blood urea nitrogen (BUN) and creatinine.

"Most patients with intra-abdominal infections demonstrate
leukocytosis (>11,000 cells/mL) with a shift to the immature
forms on the differential cell count. Patients in severe
sepsis, patients who are immunocompromised, and patients with
certain types of infections (eg, fungal, cytomegaloviral) may
demonstrate absence of leukocytosis or leucopenia.

"Blood chemistry findings are often within the reference range
initially, but they may show evidence of dehydration with
elevated BUN and altered electrolyte concentrations caused by
protracted vomiting, diarrhea, fistulae, renal dysfunction,
and ascites. Some degree of metabolic acidosis may be
present.

"Obtain a coagulation profile (ie, prothrombin time [PT] and
activated partial thromboplastin time [aPTT]) if no recent
values within the reference range are available and an
operation or interventional procedure is planned.

"Perform liver function tests (ie, alanine aminotransferase,
glutamine aminotransferase, alkaline phosphatase, total and
direct bilirubin, serum protein, albumin) if hepatic
dysfunction, malnutrition, or specific hepatobiliary disease
is suspected.

"Evaluate serum amylase and lipase levels in patients with a
possible diagnosis of pancreatitis.

"Urinalysis (UA) is essential to rule out urinary tract
diseases (eg, pyelonephritis, renal colic), which may mimic
peritonitis; however, patients with lower abdominal and
pelvic infections often demonstrate WBCs in the urine and
microhematuria. The presence of frank pyuria, WBC casts,
large numbers of red blood cells, and bacteria in the
specimen suggest a urinary source of the patient's symptoms.

"In patients with diarrhea, evaluate a stool sample for
Clostridium difficile toxin assay, WBC count, and specific
culture (ie, Salmonella, Shigella, cytomegalovirus [CMV]) if
the patient's history suggests infectious enterocolitis.

"In patients with evidence of sepsis from intra-abdominal
infection, evaluate aerobic and anaerobic blood cultures for
bacteremia; however, initial culture results may be negative
in more than 90% of cases, despite clinical evidence of
sepsis (McQuaid, 1999; Eckhauser, 1997; Pai, 1995).

"Peritoneal fluid (ie, paracentesis, aspiration of abdominal
fluid collections, intraoperative peritoneal fluid cultures)

"When assessing a peritoneal fluid sample for peritoneal
infection, evaluate the sample for pH, glucose, protein,
lactate dehydrogenase (LDH), cell count, Gram stain, and
aerobic and anaerobic cultures.

"Obtain a peritoneal fluid amylase analysis if pancreatitis or
pancreatic leak is suspected. Obtain a fluid bilirubin
analysis when a biliary leak is suspected and evaluate the
fluid creatinine level when a urinary leak is suspected.
Compare the peritoneal levels to the respective serum levels.

"The fluid in bacterial peritonitis generally demonstrates low
pH and glucose as well as elevated protein and LDH levels. A
fluid pH lower than 7.1 (and partial pressure of oxygen [PO2]
<49 mm Hg) has demonstrated positive and negative predictive
values of greater than 98% in some studies (median pH of 6.75
versus 7.49 for elective surgery, with PO2 28 versus 144 mm
Hg) (Simmen, 1993). The drop in peritoneal fluid pH (and PO2)
is more pronounced in mixed infections and severe bacterial
contamination, with increased numbers of anaerobic bacteria
in these circumstances (Sawyer RG, Spengler MD, 1991).

"In SBP, a WBC count of more than 250 cells/mL (>500 in some
studies), with more than 50% polymorphonuclear leukocytes
(PMNs) is an indication to begin antibiotic therapy. Although
up to 30% of culture findings remain negative in these
patients, most of these patients are presumed to have
bacterial peritonitis; they should be treated. A
significantly decreased peritoneal fluid glucose level (<50
mg/dL), a peritoneal fluid LDH level much greater than the
serum LDH, a peritoneal fluid WBC count greater than 10,000
cells/mL, a pH lower than 7.0, high amylase levels, multiple
organisms on Gram stain, or recovery of anaerobes from the
culture raises the suspicion of SP in these patients. Some
authors recommend repeating the paracentesis in 48-72 hours
to monitor treatment success (decrease in neutrophil count to
<50% of the original value) (Hoefs, 1985).

"In TP, the fluid Gram stain and acid-fast stain results are
rarely positive, and routine culture findings are falsely
negative in as many as 80% of cases. A peritoneal fluid
protein level greater than 2.5 g/dL, LDH level greater than
90 U/mL, and predominantly mononuclear cell count of more
than 500 cells/mL should raise the suspicion of TP, but
specificity for the diagnosis is limited. Laparoscopy with
visualization of granulomas on peritoneal biopsy and specific
culture (requires 4-6 wk) may be needed for definitive
diagnosis.

"Routine intraoperative peritoneal fluid cultures in defined
acute disease entities (ie, gastric or duodenal ulcer
perforation, appendicitis, diverticulitis or perforation of
the colon caused by obstruction or ischemia) are
controversial. Several studies have found no significant
difference in patients with appendicitis, diverticulitis, and
other common etiologies for bacterial peritonitis with regard
to postoperative complication rates or overall outcomes. The
antibiotic regimen was altered only 8-10% of the time based
on operative culture data (Bilik, 1998; Mosdell, 1991;
Farber, 1997). In patients who had previous abdominal
operations or instrumentation (eg, peritoneal dialysis
catheter, percutaneous stents) and patients with prolonged
antibiotic therapy, critical illness, and/or hospitalization,
these cultures may reveal resistant or unusual organisms that
should prompt alteration of the antibiotic strategy."

-=-=-=-=-=-=-=-=-=-=-=-

"Medical therapy: The general principles guiding the
treatment of intra-abdominal infections are 4-fold: (1) to
control the infectious source, (2) to purge bacteria and
toxins, (3) to maintain organ system function, and (4) to
control the inflammatory process.

"Medical, nonoperative interventional, and operative
treatment options are complimentary, not competitive, in
the treatment of peritoneal infections. Medical support
includes (1) systemic antibiotic therapy; (2) intensive
care with hemodynamic, pulmonary, and renal replacement
support; (3) nutrition and metabolic support; and (4)
inflammatory response modulation therapy.

"Early control of the septic source is mandatory and can be
achieved by operative and nonoperative means. Nonoperative
interventional therapies include percutaneous drainage of
abscesses and percutaneous and endoscopic stent placements.

"Operative management addresses the need to control the
infectious source and to purge bacteria and toxins. The
type and extent of surgery depends on the underlying
disease process and the severity of intra-abdominal
infection (Wittmann, 1998). Close surveillance of the
patient is mandatory. If the patient does not improve after
the initial therapy (<24-72 h), a missed focus of infection
must be sought and treated aggressively (Gallinaro, 1991).

"Treatment of peritonitis and intra-abdominal sepsis always
begins with volume resuscitation, correction of potential
electrolyte and coagulation abnormalities, and empiric
broad-spectrum parenteral antibiotic coverage."

-=-=-=-=-=-=-=-=-=-=-=-

"Surgical site infection/dehiscence

"The incidence of surgical site infection increases with the
degree of contamination; therefore, surgical site infection
occurs at much higher rates after operations for peritonitis
and peritoneal abscess (ie, 5-15% compared to <5% for
elective abdominal operations for noninfectious etiologies).
Surgical site infection may be expected if the wound is
closed in the setting of gross abdominal contamination (see
Table 4). Perioperative systemic antibiotics, the use of
wound protector devices, and lavage of the wound at the end
of therapy do not reliably prevent this complication. These
wounds should be left open and be treated with wet-to-dry
dressing changes several times a day.

"Table 4. Wound Classification and Risk for Surgical Site

"With minor contamination in otherwise healthy patients,
primary wound closure can be attempted, but this mandates
close surveillance for signs of wound infection for the
following 1-2 weeks. An alternative technique is
approximation of the skin every 1-2 inches, with placement of
Telfa or gauze wicks down to the fascia in between. The wound
is dressed in a sterile fashion and left undisturbed for 2-3
days. At the time of dressing change (under sterile
conditions), the amount and character of drainage is
assessed. With minimal serous drainage, the skin between the
primary suture sites can be approximated with Steri-Strips.
With turbid drainage or frank pus, open treatment is
continued by replacing the wicks 2-4 times a day.

"Impaired wound healing

"The same factors that impair clearance of the abdominal
infection contribute to increased problems related to wound
healing (eg, malnutrition, severe sepsis, multiple organ
system dysfunction, advanced age, immunosuppression) and
should be addressed aggressively. Patients with severe
abdominal infections demonstrate higher incidences of fascial
dehiscence and incisional hernia development, requiring later
reoperation.

"Complications related to percutaneous drainage

"Percutaneous drainage procedures carry a risk of related
significant complications of less than 10% (range 5-27%)
depending on the underlying pathology and abscess location.
These complications include bleeding, injury, erosion,
transgression of small and large bowel, fistula formation,
and others. Strategies to prevent these problems include
correction of coagulation problems and determination of the
exact etiology, location, and anatomic relationships of the
abscess. Indication for percutaneous treatment of complex
abscesses and patients with a persistent enteric leak should
be reviewed critically, and operative treatment should not be
delayed with lack of adequate patient improvement."

"Persistent infection, recovery of enterococci, and
multidrug-resistant gram-negative organisms, as well as
fungal infection, are related to worse outcomes and recurrent
complications (Berger, 1998).

"Patients older than 65 years have a 3-fold increased risk of
developing generalized peritonitis and sepsis from gangrenous
or perforated appendicitis and perforated diverticulitis than
younger patients and are 3 times more likely to die from
these disease processes (Watters, 1996). Older patients with
perforated diverticulitis are 3 times more likely than
younger patients to have generalized rather than localized
(ie, pericolic, pelvic) peritonitis. These findings are
consistent with the hypothesis that the biologic features of
peritonitis differ in elderly persons, who are more likely to
present with an advanced or more severe process than younger
patients with peritonitis.

"Overall, studies suggest that host-related factors are more
significant than the type and source of infection with regard
to the prognosis in intra-abdominal infections (Pacelli, 1996)"

-=-=-=-=-=-=-=-=-=-=-=-

"FUTURE AND CONTROVERSIES
Section 9 of 11 

"IOPL remains a controversial area in the operative treatment
of peritoneal infections. Individual studies report positive
effects of IOPL (see Intraoperative lavage). However,
although removal of gross contamination appears logical, the
addition of antimicrobial or antiseptic agents or
large-volume IOPL has been associated with disturbance of
peritoneal surface integrity and alteration of peritoneal
immune function. Overall, the benefits or safety of
crystalloid or antiseptic IOPL has not been established
clearly beyond any reasonable doubt, but it remains well
entrenched in modern surgical practice (Schein, 1998)."



=o-o= =o-o= =o-o= =o-o= =o-o= =o-o= =o-o= =o-o=


Your original Questions:
1). What is the Solution for this problem?
2). How long will it take to heal?
3). Do we have to conduct any additional tests?
4). What precautions has to take?


1) What I have read, suggests that in a case that is not
exacerbated by other medical conditions or age related issues,
surgery should be performed. A thorough cleansing and evacuation,
with an exploration to find the source of the fecal outflow.
If this has continued up to this point there must be a
perforation remaining. Either the appendectomy wound has not
sealed or there are other holes in the bowels. These need to be
taken care of immediately! Organ failure can result if this
continues.

2) Only after the recurring source of sepsis and fecal spillage
is fixed can the healing begin. Until then nothing will resolve.
In fact many items I have read indicate that a deteriorating
factor can occur that can result in mortality.

[ http://www.emedicine.com/med/topic2737.htm ]
"Patients who develop tertiary peritonitis demonstrate
significantly longer lengths of stay in the ICU and hospital,
higher organ dysfunction scores, and higher mortality rates
(50-70%). Resistant and unusual organisms (eg, Enterococcus,
Candida, Staphylococcus, Enterobacter, and Pseudomonas species)
are found in a significant proportion of cases of tertiary
peritonitis. Most patients with tertiary peritonitis develop
complex abscesses or poorly localized peritoneal infections that
are not amenable to percutaneous drainage. Antibiotic therapy
appears less effective compared to all other forms of peritonitis
(Nathens, 1998). "

"With minor contamination in otherwise healthy patients,
primary wound closure can be attempted, but this mandates
close surveillance for signs of wound infection for the
following 1-2 weeks. An alternative technique is
approximation of the skin every 1-2 inches, with placement of
Telfa or gauze wicks down to the fascia in between. The wound
is dressed in a sterile fashion and left undisturbed for 2-3
days. At the time of dressing change (under sterile
conditions), the amount and character of drainage is
assessed. With minimal serous drainage, the skin between the
primary suture sites can be approximated with Steri-Strips.
With turbid drainage or frank pus, open treatment is
continued by replacing the wicks 2-4 times a day. "

"Indication for percutaneous treatment of complex abscesses and
patients with a persistent enteric leak should be reviewed
critically, and operative treatment should not be delayed with
lack of adequate patient improvement."

3) Tests... Fecal matter is discharging. Only tests that
are indicated with such a strong presentation of a condition
such as that is exploration of the wound either non-invasively
(ultrasound, CT, MRI) or surgically by endoscopic survey or
in this case open abdominal surgery. The source of bowel
perforation needs to be found.

This is considering the hospital did the battery of tests
indicated for a peritoneal infection that I listed above
under Lab Studies?

4) Precautions... Well, this patient needs to be in a hospital.
The hospital should have a constant drip of some strong type
of antibiotic. She should be hydrated probably also with an IV.
Postoperative of the initial surgery she should have been
treated til resolution of the sepsis and fecal seepage. She
is at risk for secondary infections at this point. Organ
damage is a large likelihood if the area is not cleaned. This
needs to be treated seriously. 




I'm sure that this might have raised others questions.
Please request any clarifications you might have
about my answers since there is a lot of medical jargon
involved.


-search techniques-
ruptured Appendix fecal
[
://www.google.com/search?num=20&hl=en&lr=&ie=UTF-8&oe=UTF-8&s
afe=off&q=ruptured+Appendix+fecal ]

"ruptured Appendix" OR appendicitis fecal OR "fecal spillage"
[
://www.google.com/search?q=%22ruptured+Appendix%22+OR+appendi
citis+fecal+OR+%22fecal+spillage%22&num=20&hl=en&lr=&ie=UTF-8&oe=
UTF-8&safe=off ]

ruptured Appendix fecal drainage
[
://www.google.com/search?num=20&hl=en&lr=&ie=UTF-8&oe=UTF-8&s
afe=off&q=ruptured+Appendix+fecal+drainage ]

fecal drainage peritonitis
[
://www.google.com/search?q=fecal+drainage+peritonitis&num=20&
hl=en&lr=&ie=UTF-8&oe=UTF-8&safe=off&start=20&sa=N ]

Searches also through [ http://www.emedicine.com/ ]


good luck,
-AI

I agree that a white blood cell count, and urea and electrolyte tests
will provide further information about what is happening. There may
well be a low-grade infection that isn't being fully controlled by the
antibiotics.

However, full-blown peritonitis always requires urgent treatment, and
it is hard to believe that such a crisis would be unnoticed by the
people providing your mother's post-operative care. If this was a case
of peritonitis, I would expect your mother to be back in hospital,
probably in the intensive care unit!   Certainly, I cannot imagine
nothing at all being done about it for two weeks.

In your query, you speak of a drain from the abscess, but you also
mention collection of fecal matter in a bag.  The bag makes it sound
more like a stoma.  Stoma patients can suffer tremendous irritation
around the incision.  There are specially qualified stoma nurses who
can advise on how best to deal with this and prevent similar problems
in the future. Another Google researcher has informed me that a
procedure known as "loop ileostomy" can be done as a temporary measure
to help allow part of the intestine to heal after surgery or an
infection.  Maybe this procedure has been carried out on your mother? 
Although the procedure diverts fecal matter to the outside of the body
before it can reach the rectum, there may still be some passage
through the rectum as well in such cases.

Really, though, this is all guesswork.  The only people who can tell
you with 100% certainty what is happening are the qualified medical
professionals who have examined and treated your mother.  Please, do
go back to them and ask for a full explanation of the situation.  If
the current doctors are not particularly helpful, insist on seeing
someone else for a second opinion.  Here at Google, we can provide you
with general information about health matters, explain terminology,
find information about types of treatments, etc, but we are not able
to give you specific advice about a specific case.  Even a medically
qualified researcher would be hesitant to make a definite statement
about an individual patient s/he has not seen and whose history s/he
has not studied.

Since the above answers, while extensive, are not based on surgical
experience and therefore are a bit off the point, I will try to supply
some info based on surgical knowledge. First of all, it's not true
that the current care necessarily needs to be in the hospital, or that
it means the surgery was not a success. Ruptured appendix can lead to
death. This patient was saved, but is suffering a complication of the
disease itself which, while not common, occurs sometimes if the damage
to the area around the appendix was severe enough before the surgery
was done. The current situation is called a fecal fistula. It is not
peritonitis. The only test that might be indicated at this point (it's
completely off-the-wall that urea and white count and electrolyte
tests will give any useful info) is a colon xray to be sure there is
nothing interfering with normal bowel passage beyond the area which is
draining. What you describe is exactly correct: as long as the bowel
movements are easy and normal, the drainage from the fistula should be
less. The fact is that if the bowel movements can be kept easy and
normal, the odds are great that eventually the fistula will heal on
its own with no more surgery needed. Diabetes slows healing; it's hard
to say how long it will take, but as long as there is no sign of
residual infection (and from what you describe it  sounds like there's
not) I'd still expect healing to occur, and would advise (1) be
patient, (2) disregard most of what's in the other answers (back in
intensive care, etc), and (3) address your concerns to her surgeon. It
sounds, so far, as if the right things are being done.

I firmly believe that the only proper answer to this query is to urge
youngerson-ga to consult a physician in person about the matter. 
Google Answers is not the place for detailed discussion of individual
medical cases.  I only entered into the exchange, because I found it
hard to believe that peritonitis could be in question and wanted to
defuse any fears caused by such a suggestion. I took advice from a
couple of trustworthy people before venturing any sort of comment. I
did not say the patient should be back in intensive care; I said that
had it been peritonitis, she would have been taken back there by her
physicians, implying strongly thereby that it is not peritonitis.

With respect to the comment that "(it's completely off-the-wall that
urea and white count and electrolyte tests will give any useful
info)":

A friend advised me that these would be useful investigations to
consider in such a situation. He is a senior consultant clinical
chemist in charge of the path labs at a large hospital.  Such tests
would have been carried out in his institution.

There's nothing to be gained by arguing the blood test issue further:
but a lab chemist has no insight into what info would aid this
surgical situation; the tests would only be done if ordered by the
treating surgeon, and there is no reason to do so based on the info
given. As to the information best to ignore, in particular the first
answer which urged re-operation is a good example of several points
made which do not apply here. As a surgeon who in fact has taken care
of the exact situation on more than one occasion, it sounds as if the
situation is under control, with the fistual likely to heal with no
specific additional treatment, assuming the anatomy of the rest of the
colon is normal and bowel movements can be maintained in a regular
fashion. As was said in several comments, the best info will come from
the treating physicians.

Ummm, I'm not sure which country surgeon-ga is from, but obviously
there is a different use of language there to decribe jobs in
medicine.  The person I spoke to is not a lab chemist (technician). 
He is a consultant, ie. he is a fully qualified doctor who has made
clinical chemistry and pathology his speciality (for the last 30
years) and is now the head of those services in his hospital.  He is a
Fellow of the Royal College of Pathologists. He daily answers requests
for advice from other doctors, including surgeons, about the
laboratory investigations required in specific cases, the meaning of
the results and the subsequent therapeutic decisions. He is also
responsible for the training of junior doctors in his speciality.

umm, well, I guess we continue to argue: the issue is a non-healing
fecal fistula. The causes of non-healing will not be elucidated by
testing urea, electrolytes or white cell count. It's wonderful that
tehuti has friends in high places. If the questioner wants to insist
on these tests, go for it. It will not add information on which to
base therapeutic decisions regarding the fistula.  A colon xray might.

I thought the main issue was the fact that the patient is in severe
pain, what can be done about it and what hygienic precautions might be
required - questions probably more appropriate for someone with a
nursing background.

As for the role of white blood cells in wound healing - I remember as
a postgraduate demonstrator castigating a medical student for his lack
of knowledge of these matters in a cell biology practical 25 years
ago.

With this, I declare my intent to refrain from further discussion of
this topic.

Youngerson, I hope your mother will make a speedy recovery.

This is a very complex question and is far beyond the scope of this
discussion group. Please, please only consult with a very experienced
surgeon regarding this condition.

Nevertheless, because this appears to be at the head of a google
search for this topic, I will answer this question thoroughly. I have
gone through a similar experience and have learned quite a lot about
this situation.

The question discussed is indeed an enterocutaneous fistula. An
enterocutaneous fistula is a connection, usually a long thin
"tunnel"-like tract between intestine (entero-) and the skin
(-cutaneous). The intestine here, presumably, is colon (since the
contents are fecal in nature).

This complication is much more rare than an abscess, following an appendectomy.

Stool (feces) continues to leak from, presumably, the cecum (first
part of the colon to which the appendix attaches) and drains through
the skin.

This can happen if the area where the appendix is tied or stapled off
(the "stump") develops a leak because the colon tissue is so damaged
by infection or the appendicitis itself that the staples or sutures
fail and feces starts to leak.

The most important maneuver is to control the leakage with a bag, as
was apparently done. Some advocate not eating until the fistula stops
draining, with IV nutrition, and to be patient for at least 5 weeks
for the tract to close. Others believe that not eating may not be
necessary, but certainly patience is definitely in order. This period
can be spent at home, in hospital, or in a skilled nursing
environment, depending on associated factors and overall health
otherwise.

During this period, nutrition, with attention to both protein intake
and salts and water intake, is crucial. Usually a "low-residue" diet,
i.e. one that does not result in much stool, is given, if a diet is
allowed. Ensure, Boost or other equivalent liquid nutrition
supplements are quite satisfactory. Otherwise, iv nutrition is given.

Laboratory values during this period of healing are useful: a WBC can
search for evidence of recurrent abscesses or infection and the need
for any further antibiotics; electrolytes, BUN (urea) and creatinine
can help ensure salt and water balance; and other indicators of
nutrition (e.g. albumin, triglycerides and other helpful tests) can
keep tabs on nutrition.

In addition, a drain in the fistula tract can be quite helpful in
keeping the tract clear of feces. Such a drain can actually be run
through a special type of bag called a "wound-care collection bag."

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There are some factors that will prevent a fistula from closing by
itself with time alone.

Among these is a "foreign body" (such as a sponge left in the surgical
area), radiation (presumably not a worry in this case), persistent
infection (an abscess), inflammatory bowel disease (Crohn's disease or
ulcerative colitis), tumor (unfortunately a 60 year old is in a risk
group for a colon tumor), and obstruction. Also, if it really is
indeed a "stoma", i.e. a short but wide connection between the colon
and the skin, this may not heal spontaneously.

As recommended above, a WBC (white blood count) is useful to evaluate
for persistent infection, such as an abscess. Abscess following
perforated appendectomy can occur 20% of the time and a WBC is the
first test in detecting it. Most fistulae (fistulas) actually begin as
abscesses that then work their way to the skin and then break through,
draining through the skin.

It is quite important to control such an abscess. That is why a drain
is often important.

A CT scan is the next most important test. This can hopefully detect
an abscess, tumor, or Crohn's disease, and with contrast (orally
and/or rectally throughout the colon) can also determine if there is
any obstruction. If the contrast is sufficient, it may also show the
leak and conmfirm that it is indeed from the site of the appendectomy.
(In cases of Crohn's disease or ulcerative colitis, or in the event of
an injury to nearby bowel during the appendectomy itself, the leak
could be from a site other than the appendiceal "stump".)

An alternative, as suggested above, is a colon x-ray with contrast
rectally to show the entire colon to the appendiceal site (and perhaps
a small bowel follow through to evaluate the nearby "small intestine"
as well).

Lastly, and in some practitioner's minds, firstly, an x-ray with
contrast through the skin opening (fistula tract) may give a lot of
information about the course and connection of the fistula tract.

However, there are some ways to be fooled by the x-rays. Crohns
disease and tumors can be missed or mis-interpreted. A very
experienced surgeon (as well as radiologist) is invaluable in
reviewing the studies.

As pointed out, 20% of perforated appendectomies can result in an
abscess subsequently. This can occur after open or laparoscopic
appendectomies [cf. Arch Surg Nov 2001; 136(11):1327)].

Unless such an abscess is adequately drained (either by CT scan or
additional operation, as apparently done in this case), the fistula
can persist or can become complex. Some people therefore insist on a
drain in addition to the bag, as previously mentioned.

An persistent abscess or other areas or retained pus can be
problematic. Obstruction of any part of the intestines can result from
"adhesions" after infection. Free pus causes intestines and the
omentum (an apron of fat within the abdomen) to become matted together
in an attempt to "wall off" the pus. This matting together can cause
problems, because kinking or obstruction of the intestines can occur.
If the intestines are kinked or narrowed, it can cause a partial or
complete obstruction. If bowel movements are normal, there is not
likely a complete obstruction. However, persistent pain can signal a
partial obstruction (a fistula alone is usually painless).

In such a situation, examination of the intestines with a contrast
x-ray (either CT scan or contrast enema/small bowel follow through) is
very important, as mentioned above.

After 5 weeks, a fistula that has not closed spontaneously is much
less likely to close without re-operation. Before considering
operation, the x-rays outlined are especially important.

Lastly, antibiotics may not be very helpful in the long run, and in
fact may be harmful. They do not generally help an enterocutaneous
fistula to close, unless an associated infection is being treated.
Long term antibiotics for the fistula alone only lead to resistant
organisms. A drain in the fistula tract is much more helpful at
keeping the tract clean than are antibiotics.

As to the care required for such a person at home, there is a bit of
work involved with the care of the bag. Many people live at home with
ostomy bags for various reasons, though, and this should not
necessarily be an obstacle. The precautions which we take in everyday
lives regarding stool of any sort should of course be relevant. A
nursing degree is not required to take care of an ostomy bag.

Again, this is a situation that can be quite complex and requires a
very experienced surgeon. There are instances where enterocutaneous
fistulae have persisted or become recurrent for 10 or 20 years.
Operations on these fistulae are very delicate, time consuming
procedures that ought not to be undertaken by inexperienced surgeons.