Primary aortoenteric fistula

BACKGROUND: A primary aortoenteric fistula (PAEF) is a rare clinical entity that results in fatal exsanguination if undiagnosed. The present study investigates whether management and survival have altered over time. METHODS: A Medline search was conducted for the period from January 1994 to December 2003. Data were categorized and compared with reviews of PAEF published before this interval. RESULTS: The classical triad (gastrointestinal bleeding, pain and a pulsating mass) was present in only 11 per cent of 81 patients. Most PAEFs were caused by an aneurysmal aorta and were almost always (94 per cent) heralded by repetitive gastrointestinal bleeds. Computed tomography (CT) provides images superior to those of other diagnostic modalities, such as gastroduodenoscopy or conventional angiography. Operative mortality rates were lower in later years possibly owing to improvements in perioperative care and the advent of endovascular techniques. CONCLUSION: Gastrointestinal bleeding combined with a negative endoscopy in the presence of an aneurysmal aorta suggests PAEF and requires urgent evaluation by CT. Endovascular operation is an attractive treatment option.     

Primary aortoenteric fistula

A 78-year-old woman presented with a gastrointestinal hemorrhage and palpable abdominal aortic aneurysm. The computed tomography scan of the abdomen showed a primary aortoenteric fistula. The challenging clinical diagnosis of aortoenteric fistulae and their surgical treatment options are discussed.     

腹主动脉肠瘘六例的诊治体会

目的探讨腹主动脉肠瘘的临床表现特征和治疗经验。方法对我院６例腹主动脉肠瘘进行回顾性分析。结果６例病人,男女各３例,年龄２５～７０岁;４例病理检查为动脉粥样硬化性腹主动脉瘤,年龄均６０岁以上,２例动脉中层发育不良,年龄为２５岁和３２岁;４例术前有小量多次上消化道“信号性出血”,２例突发大出血,术前诉腰部背部疼痛４例;５例为肾下型腹主动脉瘤,１例为胸腹主动脉瘤;瘘口部位３例在十二指肠第三段,２例空肠上段,１例横结肠;４例手术,２例行人造血管移植,均生存至今,１例双侧腋股动脉旁路,１例术中未找到出血部位,后２例术后死亡;另２例未来得及手术死亡。结论术前确诊腹主动脉肠瘘不容易,凡患者腹部有搏动性动脉瘤,腹部或背部剧烈疼痛,上消化道少量多次出血,应积极手术治疗。     

原发性主动脉瘤消化道瘘患者的围手术期护理

目的:探讨原发性主动脉瘤消化道瘘围手术期的护理措施,提高患者生存率。方法:回顾性总结9例原发性主动脉瘤消化道瘘的护理,术前病情观察,术后并发症的护理。结果:9例中4例在入院三天内因消化道出血未能手术而死亡,5例在行急诊手术中2例因大出血死亡,1例因多器功能衰竭死亡,2例虽然术后出现高热,肺部感染,呼吸衰竭,失血性休克,心衰等严重并发症,但经精心治疗护理后痊愈出院。结论:术前严密细致病情观察及术后并发症的正确护理,对提高手术成活率具有重要作用。     

Anastomotic ulcer-induced aortoenteric fistula after esophagogastroplasty.

A 67-year-old woman underwent an esophagogastrectomy and esophagogastrostomy for carcinoma of the distal esophagus. She died of massive hematemesis and exsanguination on the 14th postoperative day. An acute peptic ulcer-induced aortoenteric fistula was present at the anastomotic line. The literature on peptic ulcer-induced aortoenteric fistulas after esophagogastroplasty is reviewed.     

Primary aortoenteric fistula associated with giant aortic pseudoaneurysm

Aortoenteric fistula is a very rare pathology that may cause catastrophic complications and even death. We present here a case of primary aortoenteric fistula associated with giant aortic pseudoaneurysm that has been treated successfully with surgical intervention.     

A case of aortoenteric fistula with iliac embolization

A sixty-eight year-old woman complained of acute hematemesis and numbness of the right lower extremity. Physiocal examination on amission demonstrated revealed a pulsating mass in the midabdomen, absence of pulsation of the right femoral artery and cold pale skin of the right leg. The diagnosis of abdominal aneurysm with aortoenteric fistula and embolization embolectomy to the right iliac artery was mode by computed tomography although the fistula was not clearly visualized. The abdominal aneurysm was replaced with a Y-graft after embolectomy and the fistula to the duodenum was completely closed. Early diagnosis and emergency surgery are necessary to save the patient with this rare disease.     

Primary aortoenteric fistula. Report of a case

Primary aortoenteric fistulas (PAEF) are rare entities associated with a high mortality. Although several causes have been reported, their occurrence is usually due to erosion of an abdominal aortic aneurysm into the intestinal tract. The most common sites for the fistula are the third and fourth portions of duodenum. The classical triad of gastrointestinal hemorrhage, abdominal mass and abdominal or back pain, though highly suggestive for PAEF, is uncommon. The typical bleeding pattern associated with PAEF is characteristically intermittent, starting with a brief "herald bleeding" followed eventually by major gastrointestinal hemorrhage, often with fatal outcome. The pre-operative examinations are often not helpful and can lead to delayed diagnosis and surgery. In a patient with risk factors for atherosclerosis and significant upper gastrointestinal bleeding in the absence of an evident source, PAEF should be suspected. A high index of suspicion of this condition allows correct diagnosis and definitive treatment to be carried out. If PAEF is suspected and the patient is unstable the surgeon should be prepared to skip the preoperative investigations in favour of early surgical exploration. Definitive treatment includes primary duodenal repair and aortic aneurismal resection with graft "in situ" replacement. The authors present a successfully treated case and stress the importance of clinical suspicion in order to achieve correct diagnosis and treatment.     

Recurrent aortoenteric fistula: case report and review

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.     

Upper gastrointestinal bleeding due to primary aortoenteric fistula

Primary aortoenteric fistula (PAEF) is a rare but clinically important cause of catastrophic gastrointestinal bleeding. "Herald bleeding" is a characteristic symptom which refers to specific case of upper gastrointestinal bleeding that stop temporarily spontaneously and then proceeds to massive bleeding. We present the case report of a 55-year-old male with PAEF who was admitted due to upper gastrointestinal bleeding. Endoscopic studies were unremarkable and patient underwent exploratory laparotomy. The postoperative course was uneventful. A high index of suspicion, early diagnosis and prompt appropriate surgical intervention are crucial for survival of patient with PAEF. Gastrointestinal bleeding combined with a negative endoscopy suggests PAEF. Endovascular operation is an attractive treatment option.     

Recurrent aortoenteric fistula: two different bridge solutions

A "recurrent" aortoenteric fistula (AEF) is very rare and in literature anecdotic. Currently, graft excision and extra-anatomic bypass are considered the treatments of choice, but are associated with significant mortality and morbidity. Herein, we describe the case of a "recurrent" AEF treated before definitive extra-anatomic bypass, by two different, staged bridge solutions: allograft in situ replacement and endovascular grafting. At 1, 3 and 6-month follow-up, the patient was asymptomatic and normally active.     

Secondary aortoenteric fistula: A 20 year experience

During a 20 year period at the Johns Hopkins Medical Institutions, 17 patients were operated on for secondary aortoenteric fistula. The interval from initial operation to the onset of symptoms varied greatly and averaged 2.8 years. Symptoms included not only gastrointestinal bleeding but also sepsis and abdominal or back pain. Associated advanced cardiovascular disease was common. Helpful preoperative diagnostic studies included esophagogastroduodenoscopy, aortography, barium contrast gastrointestinal series and groin sinography. However, a high index of suspicion was the most important element of diagnosis. Overall operative mortality was high (47 percent). All six patients with a graft left in the retroperitoneum had an unsatisfactory result (four instances of recurrent aortoenteric fistula). Successful repair was accomplished only in those patients undergoing graft excision and axillofemoral bypass.     

Improvements in the diagnosis and management of aortoenteric fistula

To assess the impact of an aggressive approach (early operation, graft removal, and extraanatomic bypass) adopted by us 5 years ago in patients with aortic synthetic grafts and gastrointestinal bleeding, we reviewed our 15 year experience with aortoenteric fistula in 13 patients. The courses of six patients from the recent series (1979 through 1984) were contrasted with those of seven patients from our earlier series (1968 through 1978). Twelve of 13 patients presented with gastrointestinal bleeding (usually low volume), and no patient presented in shock. Six of seven patients in Series I (earlier series) had positive blood cultures, whereas only two of six in Series II (recent series) had this finding. Of the 13 patients, 10 underwent preoperative endoscopy. It was only with consistent visualization of third and fourth portions of the duodenum that a diagnosis of aortoenteric fistula was established (three of four patients 75 percent). Although the upper gastrointestinal series was abnormal more frequently (five of seven patients, 71 percent) than arteriograms (three of nine patients, 33 percent), the latter was more specific for a predisposing lesion. At surgery, nine (70 percent) patients had an anastomotic fistula and four (30 percent), a false aneurysm. Although only one of seven patients in Series I survived (14 percent), four of six patients in Series II were alive at last follow-up in September 1984 (67 percent). Early diagnosis followed by prompt operation with removal of the synthetic graft and extraanatomic bypass is associated with an improved survival for patients with aortoenteric fistula, but the degree of preoperative sepsis as indicated by positive blood cultures appears to be an important prognostic sign.     

Primary aortoenteric fistula: report of six new cases

Primary aortoenteric fistula (PAEF) is defined as a communication between the native aorta and the gastrointestinal tract, in contrast to secondary fistulas, which arise between a suture line of a vascular graft and the intestine. Arteriosclerosis is the predominant cause of PAEF and accounts for more than two-thirds of the cases reported. The pathogenesis is usually based on direct adhesion of a segment of the gastrointestinal tract to an aortic aneurysm, followed by progressive erosion through the bowel wall. The clinical presentation is usually one of intermittent gastrointestinal haemorrhage resulting in lethal exsanguination. Pain in the abdomen, a pulsatile abdominal mass or fever may be present. The choice of various diagnostic procedures is often decided by the clinical presentation. Esophagogastroduodenoscopy, ultrasound and CT scan may be useful in the evaluation of these patients. Current recommendations for repair include debridement of the aneurysmal aorta, repair with an in situ graft and primary repair of the gastrointestinal tract, followed by aggressive antimicrobial therapy. We present six cases of PAEF surgically treated at the St. Radboud Hospital, the Canisius Wilhelmina Hospital in Nijmegen and the Lukas Hospital in Apeldoorn over a period of 15 years.     

原发性主动脉消化道瘘九例临床分析

目的　提高主动脉消化道瘘的诊治水平。 方法　对９ 例主动脉消化道瘘病例进行回顾性临床分析,并结合文献对该病的流行病学特征、临床诊治进行探讨。 结果　主动脉消化道瘘发生率占同期收治消化道出血的０－０７２％ （９／１２ ４３１） ,占同期胸腹主动脉瘤的３－４％ （９／２６２） 。９ 例中男５例,女４ 例,平均年龄５６－８ 岁。均有预兆性出血特征,腹部搏动性包块和休克,６ 例出现腹痛,所有特殊检查均未能诊断主动脉消化道瘘。术中或尸解诊断主动脉十二指肠瘘４ 例,主动脉空肠瘘３ 例,主动脉横结肠瘘１ 例,主动脉食管瘘１ 例。９ 例中有５ 例行急诊手术,共有７ 例死亡,２ 例存活。３ 例行主动脉瘤及肠瘘手术,其中原位人工血管置换术２ 例存活。 结论　临床对具有出血、腹痛、腹部搏动性包块三联征,影像学检查发现患有胸腹主动脉瘤者,应高度怀疑主动脉消化道瘘可能。迅速积极的手术是唯一有效抢救病人的治疗方法     

Efficacy of 3-D computed tomographic reconstruction in evaluating anatomical relationships of colovesical fistula

A case of colovesical fistula is reported. The anatomy of the pelvis was determined preoperatively with 3-D computed tomography (CT), and the fistula, including adjacent structures, could clearly be seen. Compared with conventional axial CT imaging, 3-D CT provided better and more complete visualization of the anatomical relationships, which facilitated the surgical procedure and provided a good outcome.