Guideline sources The following summarized guidelines for the evaluation and management of enterocutaneous fistula (ECF) are prepared by our editorial team based on guidelines from the American Society of Colon and Rectal Surgeons (ASCRS 2020), the British Society of Gastroenterology (BSG 2019), the American College of Gastroenterology (ACG 2018), and the Latin American Federation of Nutritional Therapy, Clinical Nutrition and Metabolism (FELANPE/ASPEN 2017). 1 2 3 4 Guidelines 1. Diagnostic investigations Nutritional evaluation: assess patients with ECF for malnutrition at the time of diagnosis. Obtain periodic nutrition assessment if malnutrition is not present at baseline as patients with fistulas have a high likelihood of becoming malnourished due to nutrient malabsorption, fluid and electrolyte losses, and sepsis. B Show 2 more 2. Medical management Immunosuppresive therapy: As per BSG 2019 guidelines, consider initiating immunomodulator and biological therapy for the management of patients with IBD and low volume ECFs. C Show 2 more https://web.pathway.md/diseases/recmi48m0maRYKs5O 1/2 6/29/23, 4:17 AM Enterocutaneous fistula Pathway As per ACG 2018 guidelines, consider initiating infliximab in patients with Crohn's disease and ECF. B Show 2 more Somatostatin analogs: initiate somatostatin analogs as an option to reduce effluent drainage and enhance spontaneous closure in adult patients with high-output (> 500 mL/day) ECF. B 3. Nonpharmacologic interventions Nutritional support: consider initiating oral diet or enteral nutrition after stabilization of fluid and electrolyte balance in adult patients with low-output (< 500 mL/day) ECF (suggesting no distal obstruction). Consider initiating parenteral nutrition to meet fluid, electrolyte, and nutrient requirements to support spontaneous or surgical closure of the ECF in patients with high- output fistula (> 500 mL/day). C Show 5 more 4. Surgical interventions Indications for surgery: As per ASCRS 2020 guidelines, consider performing surgery in patients with Crohn's disease and enteric fistulas persisting despite appropriate medical therapy. B As per BSG 2019 guidelines, offer surgery to achieve symptom control in patients with IBD and high-volume fistulas. B References 1. Vanessa J Kumpf, Jose Eduardo de Aguilar-Nascimento, Jose Ignacio Diaz-Pizarro Graf et al. ASPEN FELANPE Clinical Guidelines. JPEN J Parenter Enteral Nutr. 2017 Jan;41 1 104 112. Open 2. Lamb CA, Kennedy NA, Raine T et al. British Society of Gastroenterology consensus guidelines on the management of inflammatory bowel disease in adults. Gut. 2019 Dec;68 Suppl 3):s1-s106. Open 3. Amy L Lightner, Jon D Vogel, Joseph C Carmichael et al. The American Society of Colon and Rectal Surgeons Clinical Practice Guidelines for the Surgical Management of Crohn's Disease. Dis Colon Rectum. 2020 Aug;63 8 1028 1052. Open 4. Lichtenstein GR, Loftus EV, Isaacs KL et al. ACG Clinical Guideline: Management of Crohn's Disease in Adults. Am J Gastroenterol. 2018 Apr;113 4 481 517. Open https://web.pathway.md/diseases/recmi48m0maRYKs5O 2/2