C- reactive protein-to-Prealbumin ratio as a predictor for enterocutaneous fistula closure

Abstract

Enterocutaneous fistula is a challenging clinical condition with serious complications and considerable morbidity and mortality i.e. malnutrition, sepsis, and fluid and electrolyte disturbances, known as the “fistula triad”. Early nutritional support has been found to decrease these complications and to improve the clinical outcome. Location of the fistula and physiological status affect the nutrition management plan in terms of feeding route, calories, and protein requirements. The management plan is usually divided into four phases. The first and second phases are recognition and stabilization, includes resuscitation of the patient, control of sepsis, electrolyte repletion, control of fistula drainage, and supply of nutrition. In the third phase, radiological investigations are performed to identify the anatomy and characteristics of the fistula. In the fourth phase, a decision is taken regarding the duration of conservative management and the operative plan based on an evaluation of the patient and the fistula. Nutritional support involves assessment, diagnosis, ordering, preparation, distribution, administration, and monitoring of nutrition. It includes total parenteral nutrition (TPN), enteral feeding, or oral feeding, and plays a major role in management of enterocutaneous fistula. It begins with calculating calories and protein requirements, assessing tolerance of the feeding regimen, modifying feeding methods, adjusting nutritional requirements according to changes in clinical status, and finally, observing for feeding complications. Classification of the fistula affects the route of feeding and caloric and protein requirements; i.e, patients with high output fistula should receive more calories and protein than those with low output fistula who mostly require TPN. Oral and enteral feeding increase the fistula output if the fistula occurs in the proximal part of the gut. Therefore, a multidisciplinary team should be involved in designing and performing the management plan. Despite attention to nutritional support, malnutrition remains a major clinical problem in 50%–90% of patients with enterocutaneous fistula. The ratio of CRP to PAB has been correlated with multiple organ dysfunction and has been useful in the diagnosis of post-operative infection even before clinical symptoms developed. The C-reactive protein to prealbumin ratio has been shown to predict mortality in critically ill patients. The use of such a ratio makes sense given that it incorporates both a measure of inflammation and an acute measure of nutrition, both are important in fistula healing or nonhealing.