Primary aortoduodenal fistula caused by tuberculous aortitis presenting as recurrent massive gastrointestinal bleeding. J Formos Med Assoc. 2008;107:77-83. [PMID: 18218582 DOI: 10.1016/s0929-6646(08)60012-1]

Primary Aorto-Enteric Fistula With a Subsequent Secondary Aorto-Enteric Fistula

Objective

Primary aorto-enteral fistula (PAEF) is a connection between the gastrointestinal tract and the aorta that occurs without previous aortic surgery. The aetiological factors include, but are not limited to, aneurysm, infection, and tumours. It is a life threatening condition if untreated and requires emergency vascular surgical repair. A secondary aorto-enteric fistula (AEF) can occur to a previously reconstructed aorta. This case report presents a unique case of a male patient who developed a primary AEF and subsequent secondary AEF with successful surgical outcomes, suggested to be due to tuberculous aortitis.

Report

The patient was diagnosed and treated for tuberculosis and developed a saccular aneurysm within six months. The PAEF was surgically corrected with a tube graft using a bovine pericardial patch, the defect in duodenum was sutured, and a retrocolic omental flap was created between the duodenum and aorta. He developed a small stable pseudoaneurysm during follow up, and then a secondary AEF two and a half years later, in which a connection between the pseudoaneurysm and duodenum was corrected using a new bovine aorto-aortic interposition graft using a bovine pericardium patch. The defect in the duodenum was also sutured in two layers and a new omental flap was created.

Discussion

The mortality rate of AEF is high and it is very unlikely that a patient will survive two AEFs without major complications. It is believed that there are extremely few double AEF cases described in the literature. The aetiological factor in the development of PAEF in this case was most likely the patient's aortic aneurysm, which was most likely of mycotic origin due to tuberculosis. The patient developed a pseudoaneurysm during follow up and it is uncertain whether the pulsatile pressure of the pseudoaneurysm led to the recurrence of the AEF.

The management of postoperative upper alimentary tract fistulas: A single-center experience of endoscopic tissue glue repair and recommendations of a systematic review

BACKGROUND/PURPOSE

The appropriate management of postoperative upper alimentary tract fistula (UATF) remains uncertain. The efficacy of esophagogastroduodenoscopy (EGD) tissue glue repair in the treatment of patients with postoperative UATF was explored. We also conducted a systematic review of the literature regarding the inpatient management of UATF.

METHODS

Totally 24 patients received EGD tissue glue repair for postoperative UATF at our institute from April 2014 to April 2020. Independent characteristics of size of fistula, location of the UATF, complications, and recurrences were analyzed. PubMed and Cochrane Library databases were reviewed. A pooled analysis was performed, and subgroup analysis was conducted separately for different anatomic locations and techniques.

RESULTS

With a mean follow-up of 40 months, the fistula failed to close with EGD tissue glue repair in 2 of 24 patients (8.3%). Eight patients required repeated EGD tissue glue repair, which was more frequent in oral or thoracic UATF (p = 0.053), but all achieved a successful seal in the EGD tissue after glue repair alone (n = 22). The fistula size was correlated with the demand for repeated EGD tissue glue repair (p = 0.017). Besides, a total of 30 studies regarding 2356 cases of postoperative UATF between 2010 and 2021 were retrieved and analyzed. Several non-operative methods were generally accepted as the initial approach, with a non-inferior success rate compared to operative techniques.

CONCLUSIONS

The results suggest that no single approach toward UATF is superior in terms of success rate and healing time. The potential advantages of EGD tissue glue repair after drainage were more suitable for patients with postoperative UATF and multiple comorbidities.

Endoscopic treatment of primary aorto-enteric fistulas: A case report and review of literature

BACKGROUND

Primary aorto-enteric fistula (PAEF) is a rare condition, traditionally treated in the acute, bleeding phase with open surgery or endovascular repair. However, these approaches have high morbidity and mortality, indicating a need for new methods. With advances in endoscopic techniques and equipment, haemoclipping of fistulas has now become feasible. Therefore, we present a systematic review of the English literature and a rare case of a PAEF successfully treated by endoscopic haemoclipping.

CASE SUMMARY

A 74-year-old man with an abdominal aortic aneurysm presented with symptoms of haemorrhagic shock and bloody stools. An oesophago-gastro-duodenoscopy was performed with haemoclipping of a suspected PAEF in the third part of the duodenum. Afterward, a computed tomography-angiography showed a contrast filled protrusion from the abdominal aortic aneurysm. Based on the clinical presentation and the combined endoscopic and radiographic findings, we argue that this is a case of a PAEF.

CONCLUSION

Endoscopic therapy appears capable of achieving haemodynamic stabilisation in patients with bleeding PAEF, serving as a bridge to final therapy.

Gastrointestinal Tuberculosis

Gastrointestinal tuberculosis (TB) is a fascinating disease which can be observed both in the clinical context of active pulmonary disease and as a primary infection with no pulmonary involvement. It represents a significant clinical challenge because of the resurgence of TB as well as the diagnostic challenges it poses. A high clinical suspicion remains the most powerful tool in an era of medicine when reliance on diagnostic technology increases. Antimicrobial therapy is the mainstay of therapy, but surgical and endoscopic interventions are frequently required for intestinal TB. Gastrointestinal TB is truly the "great mimic" and continues to require the astute clinical acumen of skillful clinicians to diagnose and treat.

Potentially lethal enteric bleeding in the ED

Spontaneous or primary aortoduodenal fistula (PADF) is an uncommon etiology of upper gastrointestinal bleeding and may potentially cause sudden and unexpected death. Early diagnosis of this disease is difficult, and the mortality rate was reported near 100% when surgery is delayed. The emergency physician (EP) plays a major role in the early diagnosis of aortoduodenal fistula. A PADF should be included in the differential diagnosis when EPs treated emergency department patients with gastrointestinal bleeding, especially those in combination with known abdominal aortic aneurysm or palpable pulsating abdominal mass. Besides, abdominal computed tomography should be considered in patients with recurrent large amount of gastrointestinal bleeding without significant endoscopic findings. Prompt diagnosis and surgical intervention may preserve the life of these patients.