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Hosseinzadeh A, Zehra J, Davarpanah MA, Farsani MM, Gorji MG, Shahriarirad R. Aortoduodenal fistula and abdominal aortic aneurysm as a complication of Brucella Aortitis managed with Insitu aortic aneurysm repair: A case report. Clin Case Rep 2023; 11:e8269. [PMID: 38054195 PMCID: PMC10694090 DOI: 10.1002/ccr3.8269] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2023] [Revised: 11/13/2023] [Accepted: 11/18/2023] [Indexed: 12/07/2023] Open
Abstract
Key Clinical Message Brucella aortitis should be one of the differential diagnoses of inflammatory aortic aneurysms. In situ repair of intermittent aortoenteric fitulae and repair of infrarenal aortic aneurysm with synthetic graft can be used in clean scarred fistulae. Abstract Arterial aneurysms are very rare complications of Brucella infection. The purpose of this case report is to document a case of abdominal aortic aneurysm and primary aorto-duodenal fistula as a complication of Brucella infection, along with the management of brucella induced aortoenteric fistula with insitu synthetic graft. We report a 53-year-old man with a complaint of abdominal pain and melena. Radiological evaluation revealed an inflammatory abdominal aortic aneurysm and a primary aorto-duodenal fistula was identified during surgery. The patient underwent laparotomy, and surgical repair of the aneurysm with a bifurcated Dacron graft, while the entry of the aorto-duodenal fistula was closed with intra-aortic sutures. One month later, the patient tested positive for the Wright agglutination test (1:80) and Coomb's test (1:640) for brucella, and was treated with doxycycline, rifampicin, and ciprofloxacin for brucellosis. Though rare, brucella aortitis should be considered as one of the differential diagnoses of inflammatory aortic aneurysms. In situ repair of intermittent aortoenteric fistula and repair of the infrarenal aortic aneurysm with synthetic graft could be considered in a clean scarred fistula.
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Affiliation(s)
- Ahmad Hosseinzadeh
- Thoracic and Vascular Surgery Research CenterShiraz University of Medical ScienceShirazIran
| | - Jumana Zehra
- School of MedicineShiraz University of Medical ScienceShirazIran
| | | | | | - Meghdad Ghasemi Gorji
- Thoracic and Vascular Surgery Research CenterShiraz University of Medical ScienceShirazIran
| | - Reza Shahriarirad
- Thoracic and Vascular Surgery Research CenterShiraz University of Medical ScienceShirazIran
- School of MedicineShiraz University of Medical ScienceShirazIran
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Kuo CL, Chen CF, Su WK, Yang RH, Chang YH. Rare finding of primary aortoduodenal fistula on single-photon emission computed tomography/computed tomography of gastrointestinal bleeding: A case report. World J Clin Cases 2023; 11:7162-7169. [PMID: 37946757 PMCID: PMC10631403 DOI: 10.12998/wjcc.v11.i29.7162] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/27/2023] [Revised: 09/01/2023] [Accepted: 09/22/2023] [Indexed: 10/13/2023] Open
Abstract
BACKGROUND Primary aortoduodenal fistula is a rare cause of gastrointestinal (GI) bleeding consisting of abnormal channels between the aorta and GI tract without previous vascular intervention that results in massive intraluminal hemorrhage. CASE SUMMARY A 67-year-old man was hospitalized for coffee ground vomiting, tarry stools, and colic abdominal pain. He was repeatedly admitted for active GI bleeding and hypovolemic shock. Intermittent and spontaneously stopped bleeders were undetectable on multiple GI endoscopy, angiography, computed tomography angiography (CTA), capsule endoscopy, and 99mTc-labeled red blood cell (RBC) scans. The patient received supportive treatment and was discharged without signs of rebleeding. Thereafter, he was re-admitted for bleeder identification. Repeated CTA after a bleed revealed a small aortic aneurysm at the renal level contacting the fourth portion of the duodenum. A 99mTc-labeled RBC single-photon emission CT (SPECT)/CT scan performed during bleeding symptoms revealed active bleeding at the duodenal level. According to his clinical symptoms (intermittent massive GI bleeding with hypovolemic shock, dizziness, dark red stool, and bloody vomitus) and the abdominal CTA and 99mTc-labeled RBC SPECT/CT results, we suspected a small aneurysm and an aortoduodenal fistula. Subsequent duodenal excision and duodenojejunal anastomosis were performed. A 7-mm saccular aneurysm arising from the anterior wall of the abdominal aorta near the left renal artery was identified. Percutaneous intravascular stenting of the abdominal aorta was performed and his symptoms improved. CONCLUSION Our findings suggest that 99mTc-labeled RBC SPECT/CT scanning can aid the diagnosis of a rare cause of active GI bleeding.
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Affiliation(s)
- Chun-Liang Kuo
- Department of Nuclear Medicine, Hsinchu Mackay Memorial Hospital, Hsinchu 30071, Taiwan
| | - Ching-Fu Chen
- Department of Gastroenterology, Hsinchu Mackay Memorial Hospital, Hsinchu 30071, Taiwan
| | - Wen-Ko Su
- Department of Radiology, Hsinchu Mackay Memorial Hospital, Hsinchu 30071, Taiwan
| | - Rong-Hsin Yang
- Department of Nuclear Medicine, Hsinchu Mackay Memorial Hospital, Hsinchu 30071, Taiwan
| | - Yu-Hong Chang
- Department of Nuclear Medicine, Hsinchu Mackay Memorial Hospital, Hsinchu 30071, Taiwan
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Jaber F, Alsakarneh S, Sanders K, Ibrahim A, Ghoz H, Clarkston W, McMahon C. It Is Not Always Diverticular Bleeding: Fatal Subtle Primary Aorto-Duodenal Fistula Associated With Abdominal Aortic Aneurysm. Cureus 2023; 15:e34461. [PMID: 36874685 PMCID: PMC9980874 DOI: 10.7759/cureus.34461] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/31/2023] [Indexed: 02/03/2023] Open
Abstract
Primary aorto-duodenal fistula (PADF) is a connection between the aorta and duodenum without prior aortic surgery. We present a case of an 80-year-old female who presented with hematochezia. She was vitally stable but later developed a large episode of hematemesis followed by cardiac arrest. A computed tomography angiogram (CTA) chest scan showed an abdominal aortic aneurysm (AAA) with no leakage or rupture. Esophagogastroduodenoscopy (EGD) demonstrated blood in the stomach and duodenum, but no source was identified. Tagged RBC scan showed massive hemorrhage in the stomach and proximal small bowel. Further review of the CT images identified a subtle PADF. The patient underwent endovascular aneurysm repair but died shortly after. Physicians should maintain a high awareness of PADF, particularly in elderly patients with obscure gastrointestinal bleeding with or without known AAA. Herald bleeding in the setting of an aortic aneurysm should raise suspicion for PADF even in the absence of extravasation on CTA.
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Affiliation(s)
- Fouad Jaber
- Internal Medicine, University of Missouri-Kansas City, Kansas City, USA
| | - Saqr Alsakarneh
- Internal Medicine, University of Missouri-Kansas City, Kansas City, USA
| | - Kimberly Sanders
- Gastroenterology and Hepatology, University of Missouri-Kansas City, Kansas City, USA
| | - Ali Ibrahim
- Internal Medicine, University of Missouri-Kansas City, Kansas City, USA
| | - Hassan Ghoz
- Gastroenterology, University of Missouri-Kansas City, Kansas City, USA
| | - Wendell Clarkston
- Gastroenterology and Hepatology, University of Missouri-Kansas City, Kansas City, USA
| | - Charles McMahon
- Gastroenterology and Hepatology, Mid-America Gastro-Intestinal Consultants, Kansas City, USA
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St. Stoyanov G, Dzhenkov D, Petkova L. Primary aortoduodenal fistula: a rare cause of massive gastrointestinal hemorrhage. Autops Case Rep 2021; 11:e2021301. [PMID: 34458170 PMCID: PMC8387084 DOI: 10.4322/acr.2021.301] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2021] [Accepted: 06/04/2021] [Indexed: 01/16/2023]
Abstract
Aortoduodenal fistula (ADF) is the most common type of aortoenteric fistula (AEF). This is a rare entity, which produces communication between an abdominal aortic aneurysm (AAA) and the gastrointestinal tract (GIT), resulting in massive gastrointestinal bleeding. AEF/ADF is difficult to recognize clinically, with the classical triad of symptoms including a pulsating, palpable mass, abdominal pain, and GIT bleeding. AEF/ADF can be classified into primary when a communication between an AAA and the GIT develops with no history of prior aortic reconstructive surgery, and secondary, where the communication is on the background of previous aortic reconstructive surgery. Herein we present a case report of a 75-year-old Caucasian male patient with a clinical history of AAA, who presented with massive GIT bleeding and expired shortly after. An autopsy revealed communication between an atherosclerotic AAA and the lower third of the duodenum.
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Affiliation(s)
- George St. Stoyanov
- Medical University of Varna “Prof. Dr. Paraskev Stoyanov”, Faculty of Medicine, Department of General and Clinical Pathology, Forensic Medicine and Deontology, Varna, Bulgaria
| | - Deyan Dzhenkov
- Medical University of Varna “Prof. Dr. Paraskev Stoyanov”, Faculty of Medicine, Department of General and Clinical Pathology, Forensic Medicine and Deontology, Varna, Bulgaria
| | - Lilyana Petkova
- Medical University of Varna “Prof. Dr. Paraskev Stoyanov”, Faculty of Medicine, Department of General and Clinical Pathology, Forensic Medicine and Deontology, Varna, Bulgaria
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Kim BY, Kim KB. Primary Aortoduodenal Fistula Causes Massive Melena: A Case Report. THE KOREAN JOURNAL OF GASTROENTEROLOGY 2021; 77:132-135. [PMID: 33758109 DOI: 10.4166/kjg.2021.006] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/06/2021] [Revised: 01/20/2021] [Accepted: 01/26/2021] [Indexed: 11/03/2022]
Abstract
A primary aortoenteric fistula is defined as the spontaneous development of communication between the gastrointestinal tract and the native aorta. This is unlike a secondary aortoenteric fistula that occurs after surgery, such as a vascular graft. A primary aortoenteric fistula is an extremely rare cause of upper gastrointestinal bleeding. The condition is often overlooked because of its extremely low incidence. This paper reports a case of a 75-year-old man who presented with massive melena. Esophagogastroduodenoscopy revealed an ulcer measuring approximately 1.3 cm with a huge pulsating vessel in the third portion of the duodenum. Later, the diagnosis of primary aortoduodenal fistula was confirmed. The patient died in the preoperative stage due to massive bleeding. The findings of this case suggest that the endoscopists should recognize aortoenteric fistula as a potential cause of gastrointestinal bleeding.
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Affiliation(s)
- Byung Yen Kim
- Department of Internal Medicine, Chungbuk National University Hospital, Chungbuk National University College of Medicine, Cheongju, Korea
| | - Ki Bae Kim
- Department of Internal Medicine, Chungbuk National University Hospital, Chungbuk National University College of Medicine, Cheongju, Korea
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Bae HJ, Kim BW, Kim JS. A Rare Case of Primary Aortoduodenal Fistula. THE KOREAN JOURNAL OF HELICOBACTER AND UPPER GASTROINTESTINAL RESEARCH 2020. [DOI: 10.7704/kjhugr.2019.0042] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
Aortoduodenal fistula is a rare but life-threatening condition that can cause gastrointestinal bleeding. Due to its rarity, it is often overlooked as a cause of gastrointestinal blood loss. Notably, the mortality rate of aortoduodenal fistula is nearly 100% in undiagnosed and untreated cases. We report a case of aortoduodenal fistula, which resulted in the patient’s death. This report highlights the importance of considering even extremely rare causes of gastrointestinal bleeding in the differential diagnosis in patients with such a presentation.
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Tuma F, Crespi Z, Wolff CJ, Daniel DT, Nassar AK. Enterocutaneous Fistula: A Simplified Clinical Approach. Cureus 2020; 12:e7789. [PMID: 32461860 PMCID: PMC7243661 DOI: 10.7759/cureus.7789] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
A “fistula” is an abnormal connection between two epithelial surfaces. Fistulae are named based on the two surfaces or lumens they connect to. Fistulae form due to loss of wall integrity from an underlying insult, leading to the penetrance of an adjacent organ or epithelized surface. Common causes of small bowel fistulae include sequelae of surgical intervention, foreign body, bowel diverticula, Crohn's disease, malignancy, radiation, and infection. A histopathological analysis displays acute and/or chronic inflammation due to the underlying pathology. A thorough history and physical examination are important components of patient evaluation. Generally, patients will present with non-specific constitutional symptoms in addition to local symptoms attributed to the fistula. In rare instances, symptoms may be severe and life-threatening. Initial laboratory workup includes complete blood count, comprehensive metabolic panel, and lactate level. Radiologic imaging is useful for definitive diagnosis and helps delineate anatomy. In practice, computed tomography (CT) is the initial imaging modality. The addition of intravenous or enteric contrast may be helpful in certain situations. Magnetic resonance imaging (MRI) may also be used in special circumstances. Invasive procedures, such as endoscopy, can assist in the evaluation of mucosal surfaces to diagnose pathology such as inflammatory processes. Appropriate management should include optimizing nutritional status, delineating fistulous tract anatomy, skincare, and managing the underlying disease. A non-operative approach is generally accepted as the initial approach especially in the acute/subacute setting. However, operative intervention is indicated in the setting of failed non-operative management. Successful management of small bowel fistulae requires a multidisciplinary team approach. To conclude, a small bowel fistula is a complex clinical disease, with surgical intervention being the most common cause in developed countries. The non-operative approach should be trialed before an operative approach is considered.
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Affiliation(s)
- Faiz Tuma
- General Surgery, Central Michigan University College of Medicine, Saginaw, USA
| | - Zachary Crespi
- Surgery, Central Michigan University College of Medicine, Mount Pleasant, USA
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Makimoto S, Takami T, Shintani H, Kataoka N, Yamaguchi T, Tomita M, Shono Y, Kuroyanagi S. Cases of two patients with aortoduodenal fistula who underwent emergency operation. Int J Surg Case Rep 2020; 69:87-91. [PMID: 32305028 PMCID: PMC7163285 DOI: 10.1016/j.ijscr.2020.03.036] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2019] [Revised: 03/14/2020] [Accepted: 03/19/2020] [Indexed: 01/11/2023] Open
Abstract
Aortoduodenal fistula is a rare cause of gastrointestinal bleeding. However, it is life threatening. Diagnosis requires a high level of clinical suspicion, and surgery can offer the best chance of survival. Primary aortoduodenal fistula is often caused by aortic aneurysm without any previous vascular intervention. Secondary aortoduodenal fistula occurs after surgical treatment for abdominal aortic aneurysm.
Introduction Aortoduodenal fistula (ADF) is a rare but life-threating condition, and it is an important cause of massive gastrointestinal bleeding. Primary ADF often occurs as a result of aortic aneurysm, and secondary ADF develops after the placement of aortic prosthetic graft. Presentation of cases Case 1: A 64-year-old man with hematemesis was transferred to our hospital. The patient was diagnosed with primary ADF. Thus, we performed prosthetic graft replacement for an aortic aneurysm, and suturing of the duodenal fistula and duodenojejunal side-to-side anastomosis were performed. He was then discharged on the 35th postoperative day. After 2 years and 10 months, he died of other diseases. Case 2: A 76-year-old man with a history of abdominal aortic aneurysm repair with a prosthetic graft 5 years back who presented with hematemesis and melena was transferred to our hospital. The patient was diagnosed with secondary ADF, and an emergency endovascular aneurysm repair (EVAR) and suturing of the duodenal fistula were perfomed. He was transferred for rehabilitation purposes on the 108th postoperative day but eventually died of pneumonia 6 months after surgery. Discussion ADF is associated with high mortality. Initial bleeding is usually minor and often intermittent. However, it leads to severe bleeding and hemorrhagic shock. EVAR is preferred over open surgery because it can be performed faster and is less invasive. Recently, in case of hemorrhagic shock, EVAR is used as first-line treatment. Conclusion Accurate diagnosis and immediate treatment are important for the survival of patients with ADF.
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Affiliation(s)
- Shinichiro Makimoto
- Department of Surgery, Kishiwada Tokushukai Hospital, 4-27-1, Kamori-cho, Kishiwada City, Osaka, 596-8522, Japan.
| | - Tomoya Takami
- Department of Surgery, Kishiwada Tokushukai Hospital, 4-27-1, Kamori-cho, Kishiwada City, Osaka, 596-8522, Japan
| | - Hiroshi Shintani
- Department of Surgery, Kishiwada Tokushukai Hospital, 4-27-1, Kamori-cho, Kishiwada City, Osaka, 596-8522, Japan
| | - Naoki Kataoka
- Department of Surgery, Kishiwada Tokushukai Hospital, 4-27-1, Kamori-cho, Kishiwada City, Osaka, 596-8522, Japan
| | - Tomoyuki Yamaguchi
- Department of Surgery, Kishiwada Tokushukai Hospital, 4-27-1, Kamori-cho, Kishiwada City, Osaka, 596-8522, Japan
| | - Masafumi Tomita
- Department of Surgery, Kishiwada Tokushukai Hospital, 4-27-1, Kamori-cho, Kishiwada City, Osaka, 596-8522, Japan
| | - Yoshiharu Shono
- Department of Surgery, Kishiwada Tokushukai Hospital, 4-27-1, Kamori-cho, Kishiwada City, Osaka, 596-8522, Japan
| | - Satoshi Kuroyanagi
- Department of Cardiovascular Surgery, Kishiwada Tokushukai Hospital, 4-27-1, Kamori-cho, Kishiwada City, Osaka, 596-8522, Japan
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Kassamali F, Sharma A(R. Ileal artery pseudoaneurysm: a rare cause of gastrointestinal bleed. J Community Hosp Intern Med Perspect 2019; 9:443-445. [PMID: 31723394 PMCID: PMC6830295 DOI: 10.1080/20009666.2019.1679950] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2019] [Accepted: 09/27/2019] [Indexed: 11/22/2022] Open
Abstract
Aorto-enteric fistulas are life-threatening conditions that occur commonly between the aorta and duodenum. Our case describes a fistula between the ileal artery and small bowel. To our knowledge, ileal artery fistulas are more commonly described in surgical cases, unlike our case. This case emphasizes early diagnosis of an aorto-enteric fistula causing life-threatening gastrointestinal bleeding to improve morbidity and survival.
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Affiliation(s)
- Farah Kassamali
- Internal Medicine Resident, St. Mary’s Medical Center, San Francisco, CA, USA
| | - Atul (Ryan) Sharma
- Assistant Clinical Professor of Medicine, University of California, San Francisco, CA, USA
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Jolobe OMP. Evaluation of abdominal aortic aneurysm in patients with nonvariceal upper gastrointestinal hemorrhage. Am J Emerg Med 2018; 37:1204-1206. [PMID: 30415980 DOI: 10.1016/j.ajem.2018.11.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2018] [Accepted: 11/05/2018] [Indexed: 11/30/2022] Open
Affiliation(s)
- Oscar M P Jolobe
- Manchester Medical Society, Simon Building, Brunswick Street, Manchester M13 9PL, United Kingdom of Great Britain and Northern Ireland.
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Lin TC, Tsai CL, Chang YT, Hu SY. Primary aortoduodenal fistula associated with abdominal aortic aneurysm with presentation of gastrointestinal bleeding: a case report. BMC Cardiovasc Disord 2018; 18:113. [PMID: 29879911 PMCID: PMC5992757 DOI: 10.1186/s12872-018-0852-y] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2018] [Accepted: 05/31/2018] [Indexed: 12/26/2022] Open
Abstract
Background Primary aortoduodenal fistula (ADF) is a rare cause of gastrointestinal (GI) bleeding and is difficult to diagnose as the clinical presentation is subtle. Clinicians should keep a high level of suspicion for an unknown etiology of GI bleeding, especially in older patients with or without abdominal aortic aneurysm (AAA). Computed tomographic angiography (CTA) can be used to detect primary ADF. Open surgery or endovascular aortic repair (EVAR) for ADF with bleeding will improve the survival rate. Case presentation We report a rare case of AAA complicating ADF with massive GI bleeding in a 73-year-old Taiwanese man. He presented with abdominal pain and tarry stool for 5 days and an initial upper GI endoscopy at a rural hospital showed gastric ulcer only, but hypotension with tachycardia and a drop in hemoglobin of 9 g/dl from 12 g/dl occurred the next day. He was referred to our hospital for EVAR and primary closure of fistula defect due to massive GI bleeding with shock from ADF caused by AAA. Diagnosis was made by CTA of aorta. Conclusions A timely and accurate diagnosis of primary ADF may be challenging due to insidious episodes of GI bleeding, which are frequently under-diagnosed until the occurrence of massive hemorrhage. Clinical physicians should keep a high index of awareness for primary ADF, especially in elderly patients with unknown etiology of upper GI bleeding with or without a known AAA.
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Affiliation(s)
- Tzu-Chieh Lin
- Department of Emergency Medicine, Taichung Veterans General Hospital, No. 1650 Taiwan Boulevard Sect. 4, Taichung, 40705, Taiwan.,College of Public Health, China Medical University, Taichung, Taiwan.,Department of Nursing, College of Health, National Taichung University of Science and Technology, Taichung, Taiwan
| | - Chung-Lin Tsai
- Divison of Cardiac Surgery, Cardiovascular Center, Taichung Veterans General Hospital, Taichung, Taiwan
| | - Yao-Tien Chang
- Department of Emergency Medicine, Taichung Veterans General Hospital, No. 1650 Taiwan Boulevard Sect. 4, Taichung, 40705, Taiwan.,Department of Nursing, College of Health, National Taichung University of Science and Technology, Taichung, Taiwan
| | - Sung-Yuan Hu
- Department of Emergency Medicine, Taichung Veterans General Hospital, No. 1650 Taiwan Boulevard Sect. 4, Taichung, 40705, Taiwan. .,Department of Nursing, College of Health, National Taichung University of Science and Technology, Taichung, Taiwan. .,School of Medicine, Chung Shan Medical University, Taichung, Taiwan. .,Institute of Medicine, Chung Shan Medical University, Taichung, Taiwan. .,Department of Nursing, Central Taiwan University of Science and Technology, Taichung, Taiwan.
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