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Dimech AP, Sammut M, Cortis K, Petrovic N. Unusual site for primary arterio-enteric fistula resulting in massive upper gastrointestinal bleeding - A case report on presentation and management. Int J Surg Case Rep 2018; 49:8-13. [PMID: 29920412 PMCID: PMC6005793 DOI: 10.1016/j.ijscr.2018.05.023] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2018] [Revised: 04/30/2018] [Accepted: 05/27/2018] [Indexed: 02/07/2023] Open
Abstract
INTRODUCTION Communications between an artery and the bowel are termed arterio-enteric fistulae. These are uncommon and mainly involve the aorta and duodenum. They can cause fatal haemorrhage. A primary aorto-enteric fistula has several aetiologies, one of which is post-radiotherapy. CASE REPORT 75-year old gentleman presented with acute upper gastrointestinal bleeding and haemorrhagic shock. He had a past history of right colonic cancer treated by resection and radiotherapy. At emergency gastroscopy he became critically unstable and the procedure was unsuccessful to achieve haemostasis. After resuscitation, a CT angiogram confirmed a right ilio-duodenal fistula between the right common iliac artery and duodenum. Interventional radiology was performed and a covered stent was inserted in the right common iliac artery. The patient recovered and was subsequently discharged from hospital. Three months later, he presented once again with similar massive haematemesis. Despite all efforts to stabilise him, he passed away a few hours after this second admission. DISCUSSION This case highlights what could possibly be a limitation of interventional radiology in providing definitive treatment for such a presentation. There are no set guidelines for the management of bleeding aorto-duodenal fistulae and literature is scarce. This makes it difficult to treat and the outcome is relatively unpredictable. CONCLUSION While minimally invasive radiological techniques are invaluable in many areas and life-saving in countless emergency bleeds, cases like these should ideally not be treated by stenting alone. It would be wise to follow arterio-enteric fisula bleeds by definitive open surgical repair.
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Affiliation(s)
- Anthony Pio Dimech
- Department of Surgery - Mater Dei Hospital, Dun Karm Street, Msida, Malta.
| | - Matthew Sammut
- Department of Surgery - Mater Dei Hospital, Dun Karm Street, Msida, Malta.
| | - Kelvin Cortis
- Department of Radiology - Mater Dei Hospital, Dun Karm Street, Msida, Malta.
| | - Nebosja Petrovic
- Department of Vascular Surgery - Mater Dei Hospital, Dun Karm Street, Msida, Malta.
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Fernández de Sevilla E, Echeverri JA, Boqué M, Valverde S, Ortega N, Gené A, Rodríguez N, Balibrea JM, Armengol M. Life-threating upper gastrointestinal bleeding due to a primary aorto-jejunal fistula. Int J Surg Case Rep 2015; 8C:25-8. [PMID: 25616071 PMCID: PMC4353932 DOI: 10.1016/j.ijscr.2015.01.010] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2014] [Revised: 01/05/2015] [Accepted: 01/05/2015] [Indexed: 12/26/2022] Open
Abstract
Primary aorto-enteric fistula is an uncommon life-threating condition. Primary aorto-enteric fistula is usually caused by an untreated abdominal aortic aneurysm. The treatment of choice for aorto-enteric fistula is emergent surgery. High clinical suspicion is essential to make a correct diagnosis of aorto-enteric fistula.
Introduction Primary aorto-enteric fistula (AEF) is an uncommon life-threating condition. Only 4% of them involve the jejunum or ileum and its mortality ranges from 33 to 85%. Presentation of case A 54-year-old female was admitted to the Emergency Department with syncope and hematemesis. The esophagogastroduodenoscopy found a pulsatile vessel in the second portion of the duodenum. A computed tomography scan showed an AEF with an infrarenal aortic aneurysm and iliac artery thrombosis. During surgery, an infrarenal aortic aneurysm complicated with an aorto-jejunal fistula was found. An axilo-bifemoral bypass, open repair of the aneurysm and segmental small bowel resection with primary suture of the jejunal defect were performed. Discussion Depending on previous aortic grafting, AEF can be classified as primary or secondary. Primary AEF is usually caused by an untreated abdominal aortic aneurysm, commonly presenting an infectious etiology. The main clinical sign is a “herald” hemorrhage. The EGD is considered as the first step in diagnosing AEF. The treatment of choice for AEF is emergent surgery. Use of broad-spectrum antibiotics is mandatory in the postoperative period to avoid fistula recurrence. Conclusion AEF is a rare entity with a high mortality. High clinical suspicion is essential to make a correct diagnosis, which is crucial for the prognosis of these patients, such is the case of our patient. If hemodynamic stability is achieved, it allows to employ surgical strategies in which extra-abdominal bypass is performed before fistula is treated.
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Affiliation(s)
- Elena Fernández de Sevilla
- Department of General and Digestive Surgery, Hospital Universitari Vall d'Hebron, Passeig de la Vall d'Hebron 119-129, 08035 Barcelona, Spain
| | - Juan Andrés Echeverri
- Department of General and Digestive Surgery, Hospital Universitari Vall d'Hebron, Passeig de la Vall d'Hebron 119-129, 08035 Barcelona, Spain
| | - Miriam Boqué
- Department of Angiology and Vascular Surgery, Hospital Universitari Vall d'Hebron, Barcelona, Spain
| | - Silvia Valverde
- Department of General and Digestive Surgery, Hospital Universitari Vall d'Hebron, Passeig de la Vall d'Hebron 119-129, 08035 Barcelona, Spain
| | - Nuria Ortega
- Department of General and Digestive Surgery, Hospital Universitari Vall d'Hebron, Passeig de la Vall d'Hebron 119-129, 08035 Barcelona, Spain
| | - Anna Gené
- Department of Angiology and Vascular Surgery, Hospital Universitari Vall d'Hebron, Barcelona, Spain.
| | - Nivardo Rodríguez
- Department of General and Digestive Surgery, Hospital Universitari Vall d'Hebron, Passeig de la Vall d'Hebron 119-129, 08035 Barcelona, Spain
| | - José María Balibrea
- Department of General and Digestive Surgery, Hospital Universitari Vall d'Hebron, Passeig de la Vall d'Hebron 119-129, 08035 Barcelona, Spain
| | - Manel Armengol
- Department of General and Digestive Surgery, Hospital Universitari Vall d'Hebron, Passeig de la Vall d'Hebron 119-129, 08035 Barcelona, Spain
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Klonaris C, Vourliotakis G, Katsargyris A, Tsiodras S, Bastounis E. Primary Aortoduodenal Fistula without Abdominal Aortic Aneurysm in Association with Psoas Abscess. Ann Vasc Surg 2006; 20:541-3. [PMID: 16625413 DOI: 10.1007/s10016-006-9039-6] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2006] [Revised: 02/06/2006] [Accepted: 02/17/2006] [Indexed: 10/24/2022]
Abstract
Primary aortoenteric fistula (PAEF) is a communication between the aorta and the enteric tract without any previous vascular intervention, e.g., aortic grafting. Although rare, PAEF is a potentially lethal condition that requires a high index of suspicion and prompt surgical intervention. Most of the reported cases involve an abdominal aortic aneurysm. However, in this report, we describe a rare case of a primary aortoduodenal fistula in a nonaneurysmal aorta in association with a psoas abscess, which was treated successfully. At 2-year follow-up, the patient is alive without episodes of bleeding or fever.
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Affiliation(s)
- Chris Klonaris
- Vascular Division, 1st Surgical Department, Laikon Hospital, University of Athens Medical School, Athens, Greece.
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Goshtasby P, Henriksen D, Lynd C, Fielding LP. Recurrent Aortoenteric Fistula: Case Report and Review. ACTA ACUST UNITED AC 2005; 62:638-43. [PMID: 16293501 DOI: 10.1016/j.cursur.2005.03.022] [Citation(s) in RCA: 18] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2005] [Accepted: 03/08/2005] [Indexed: 11/29/2022]
Abstract
Aortoenteric fistulas (AEFs) are abnormal communications between the aorta and the bowel most frequently resulting from prosthetic graft erosion. Despite advances in surgery and medical technology, these entities are still associated with significant morbidity and mortality for the patient. Multiple case reports and reviews have attempted to elucidate the nature of AEFs in an effort to better characterize and manage these entities. However, reports of recurrence of this process are extremely rare. In this article, we describe a unique case of recurrence of an AEF that was successfully managed with primary aortic oversew and bowel resection. We will also review the literature on AEFs with a comprehensive overview on background, presentation, diagnosis, and current management options.
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Affiliation(s)
- Parviz Goshtasby
- Department of Surgery, Wellspan Health at York Hospital, 1001 South George Street, York, PA 17405, USA.
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Riera Vázquez R, Manuel-Rimbau Muñoz E, Julia Montoya J, Cordobés Gual J, Merino Mairal O, Lara Hernández R, Corominas Roura C, Lozano Vilardell P, Gómez Ruiz FT. [Primary aortoenteric fistula: a rare cause of gastrointestinal bleeding in young adults]. GASTROENTEROLOGIA Y HEPATOLOGIA 2005; 28:26-9. [PMID: 15691466 DOI: 10.1157/13070381] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
Aortoenteric fistula is defined as a communication between the native aorta and any portion of the gastrointestinal tract. Depending on previous aortic grafting it can be classified as primary, without previous grafting, or secondary. Primary aortoenteric fistula is less frequent and usually arises from an abdominal aortic aneurysm. Clinical presentation is usually gastrointestinal bleeding. The main diagnostic procedures are gastroscopy and computed tomography. We report the case of a 46-year-old man who presented to the emergency room with gastrointestinal bleeding and an abdominal pulsatile mass. Although complementary tests and clinical signs suggested a diagnosis of primary aortoenteric fistula, the communication was not observed on gastroscopy and was confirmed by exploratory laparotomy. Despite aggressive surgical treatment, the prognosis of this entity is poor.
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Affiliation(s)
- R Riera Vázquez
- Servicio de Angiología y Cirugía Vascular, Hospital Universitario Son Dureta, Palma de Mallorca, Spain.
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Cho YP, Kang GH, Han MS, Jang HJ, Kim YH, Ryu JH, Park CK, Lee SG. Staged surgery for chronic primary aortoduodenal fistula in a septic patient. J Korean Med Sci 2004; 19:302-4. [PMID: 15082909 PMCID: PMC2822317 DOI: 10.3346/jkms.2004.19.2.302] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/03/2022] Open
Abstract
Aortoenteric fistula is one of the most challenging problems that confront the vascular surgeons. Controversy remains over the optimal treatment because of the continued publication of series with high mortality, amputation, and aortic disruption rates. A positive preoperative blood culture is the best predictor of mortality with increased amputation rates due to infection of the extra-anatomic bypass. Therefore, in selected cases with sepsis, a prudent management protocol is required. We report a 68-yr-old male presenting with a chronic primary aortoduodenal fistula extensively involving the duodenum and Gram-negative sepsis. We planned a staged operation. Initially, an emergency laparotomy and control of the aorta allowed stabilization of the patient, identification of the fistula, and direct in situ placement of the prosthetic graft followed by an en bloc resection of the aneurysm and the surrounding structures. After he recovered from sepsis and had been stabilized, a staged extra-anatomic bypass followed by transabdominal removal of the temporarily placed graft was done. This management plan will allow the highest success rate and may be a prudent management protocol for these difficult cases.
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Affiliation(s)
- Yong Pil Cho
- Department of Surgery, University of Ulsan College of Medicine, Gangneung Asan Hospital, Gangneung, Korea.
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Kar B, Dougherty K, Reul GJ, Krajcer Z. Aortic stent-graft infection due to a presumed aortoenteric fistula. J Endovasc Ther 2002; 9:901-6. [PMID: 12546594 DOI: 10.1177/152660280200900626] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
PURPOSE To report a case of late stent-graft infection with aortoenteric fistula. CASE REPORT A 76-year-old Colombian man received an AneuRx stent-graft for a 5.5-cm infrarenal AAA. The aneurysm sac progressively shrank until 22 months postoperatively, when an increase in diameter was noted on magnetic resonance imaging without evidence of endoleak or air in the sac. Two months prior, the patient had developed fever and an elevated white blood cell count; he underwent a 6-week course of intravenous antibiotics. Shortly thereafter, the fever recurred, along with progressive weight loss, which prompted admission. The computed tomographic scan showed no evidence of endoleak, but gas collection was seen anteriorly in the sac; aspirated material was positive for a variety of organisms. At surgery 23 months after stent-graft implantation, pronounced inflammatory reaction and scarring were seen around the graft in conjunction with evidence of a healed duodenal perforation, suggestive of an aortoenteric fistula. The excised stent-graft was intact; no deterioration was seen. The patient had a protracted recovery but has been afebrile and asymptomatic >1 year after stent-graft explantation CONCLUSIONS Close surveillance after endovascular AAA repair is essential to detect late leaks, secondary migration, endotension, structural failure, and infection with or without aortoenteric fistula.
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Affiliation(s)
- Biswajit Kar
- Department of Cardiology, Texas Heart Institute, St Luke's Episcopal Hospital, Houston, Texas, USA
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Constans J, Midy D, Baste JC, Demortière F, Conri C. [Secondary aortoduodenal fistulas: report of 7 cases]. Rev Med Interne 1999; 20:121-7. [PMID: 10227089 DOI: 10.1016/s0248-8663(99)83028-8] [Citation(s) in RCA: 18] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
PURPOSE Aortoduodenal fistulas are the most frequent aortoenteric fistulas. They may be primary (occurring after aneurysms of the native aorta) or secondary (occurring after aortic prosthesis). Aortoduodenal fistulas are a rare complication of aortic prostheses. They may be caused by prosthesis infection or due to inadequate prosthesis. METHODS We report seven observations that emphasize issues pertaining to either diagnosis or therapy. RESULTS The delay of occurrence is variable, with a mean of 3 years as reported in the literature. Clinical picture includes upper digestive tract hemorrhage, sometimes fever, abdominal pain or mass. Though difficult, diagnosis can be achieved through gastric endoscopy or CT-scan. Additional diagnostic procedures are often not useful and should not be numerous. Surgical procedures help guide the diagnosis and constitute the main part of the treatment with suture of the duodenum and vascular prosthesis. According to previous works, our observations including prolonged follow-up of the patients suggest that the best vascular treatment is extra-anatomic axillo-bifemoral bypass, while simple suture and prosthesis replacement lead to poor results. CONCLUSION Mortality related to aortodigestive fistulas is high (five out of seven patients in the present study) and requires prevention, including more particularly delicate surgery and antibiotic therapy in case of any episode of infection. Aortoduodenal fistulas must be suspected whenever a patient with aortic prosthesis has digestive bleeding or unexplained fever.
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Affiliation(s)
- J Constans
- Service de médecine interne et pathologie vasculaire, hôpital Saint-André, Bordeaux
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11
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Brown PW, Sailors DM, Headrick JR, Burns RP. Primary Aortojejunal Fistula: A Case Report. Am Surg 1999. [DOI: 10.1177/000313489906500210] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Primary aortoenteric fistulae (AEFs) are extremely rare vascular entities, with fewer than 250 cases reported in the world medical literature as of 1996. Incidence is less than 1 per cent, with a mortality ranging from 33 to 85 per cent. Atherosclerosis remains the most common etiology, accounting for more than two-thirds of the cases reported. Other etiologies include carcinoma, ulcers, gallstones, diverticulitis, appendicitis, and foreign bodies. Early diagnosis is crucial for survival and mandates recognition of the typical “herald bleed.” Additional findings on initial presentation frequently include flank pain, abdominal pain, hematemesis, melena, and an abdominal mass. More than 80 per cent of primary AEFs involve the duodenum, with the overwhelming majority located in the third or fourth portion. Successful management of primary AEF requires a high index of suspicion for diagnosis and prompt surgical intervention for survival.
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Affiliation(s)
- Preston W. Brown
- Department of Surgery, Chattanooga Unit, University of Tennessee College of Medicine, Chattanooga, Tennessee
| | - David M. Sailors
- Department of Surgery, Chattanooga Unit, University of Tennessee College of Medicine, Chattanooga, Tennessee
| | - James R. Headrick
- Department of Surgery, Chattanooga Unit, University of Tennessee College of Medicine, Chattanooga, Tennessee
| | - R. Phillip Burns
- Department of Surgery, Chattanooga Unit, University of Tennessee College of Medicine, Chattanooga, Tennessee
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Affiliation(s)
- A P Varekamp
- Department of Surgery, Sint Antoniushove Hospital, Leidschendam, The Netherlands
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Voorhoeve R, Moll FL, de Letter JA, Bast TJ, Wester JP, Slee PH. Primary aortoenteric fistula: report of eight new cases and review of the literature. Ann Vasc Surg 1996; 10:40-8. [PMID: 8688296 DOI: 10.1007/bf02002340] [Citation(s) in RCA: 95] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
Primary aortoenteric fistula, a direct communication between the aorta and the intestinal tract, is a rare cause of gastrointestinal hemorrhage. Eight patients who were all treated at one hospital are described, followed by a review of all surgically treated patients reported within the past 10 years. The usual cause is erosion of an atherosclerotic aneurysm into the adherent duodenum, but a wide variety of other causes and localizations have been described. The clinical presentation is usually one of intermittent gastrointestinal hemorrhage resulting in lethal exsanguination within a matter of hours or days. Pain, a pulsatile abdominal mass, or fever may not be present. Endoscopy, arteriography, ultrasound, and CT scan can be useful in the evaluation of these patients, but physical examination and a high index of suspicion remain key to diagnosis. Primary aortoenteric fistula is more often discovered unexpectedly during exploratory laparotomy and is not usually considered as a presumptive preoperative diagnosis. Although contamination is unavoidable, most patients are treated with an in situ vascular graft and primary closure of the intestinal defect with good results.
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Affiliation(s)
- R Voorhoeve
- Department of surgery, St. Antonius Hospital, Nieuwegein, The Netherlands
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Affiliation(s)
- C D Dossa
- Department of Surgery, Henry Ford Hospital, Detroit, Mich 48202
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Affiliation(s)
- R A Yeager
- Department of Surgery, Oregon Health Sciences University, Portland
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