An autopsy case of a primary aortoenteric fistula： A pitfall of the endoscopic diagnosis

A primary aortoenteric fistula （PAEF）, defined as a communication between the native aorta and the gastrointestinal tract, is a rare cause of gastrointes-tinal bleeding. The preoperative diagnosis of PAEF is extremely difficult. Consequently, PAEF may cause sudden and unexpected death. We present an autopsy case of a 68-year-old man who died of massive gastro-intestinal bleeding due to a PAEF. Autopsy revealed a pinhole rupture located on the third part of the duode-nal mucosa and fistulized into the adjacent abdominal aortic aneurysm （AAA）. Our case indicates that the aortoenteric fistula can result in fatal gastrointestinal bleeding. Consequently, a PAEF should be included in the differential diagnosis of gastrointestinal bleeding.     

Primary aorto enteric fistula: report of 18 Belgian cases and literature review

BACKGROUND AND STUDY AIMS: We searched for Belgian cases of primary aorto enteric fistula (PAEF). After reviewing the literature we compared our data concerning incidence, types, pathogenesis, aetiology, clinical presentation, diagnostic modalities, treatment and prognosis of PAEF. We especially focus on the clinical picture and diagnostic options. PATIENTS AND METHODS: We present our atypical case report. A questionnaire was send to 196 Belgian vascular surgeons in order to evaluate retrospectively the Belgian experience with PAEF. A Medline search of relevant literature from January 1980 to February 2006 was conducted. RESULTS: In total 18 Belgian cases of PAEF were detected usually originating from infrarenal abdominal aorta (83%), ending in the third or fourth part of the duodenum (67%) and affecting men (94%) with a mean age of 70-years-old. Main cause is aneurysm (89%). Gastrointestinal bleeding is the main symptom (83%). Untreated, no one survives and overall mortality is 29%. Most patients are treated with in situ grafts (83%). With our experience we propose a diagnostic flow chart to obtain early diagnosis of PAEF. CONCLUSIONS: PAEF is suspected when a patient presents with (considerable) (upper) gastrointestinal blood loss and has a known aneurysm, initial herald bleed or pulsating abdominal mass. In case of hemodynamic instability, prompt surgical exploration is mandatory. Hemodynamically stable patients must undergo contrast enhanced multislice computerized tomography rather than gastroduodenoscopy or arteriography to make early diagnosis. Surgery is the only definitive life saving treatment. Overall mortality is at least 30%. Late diagnosis, positive peroperative cultures and shock are indicators of poor prognosis.     

ENDOSCOPIC IMAGE OF SECONDARY AORTOENTERIC FISTULA

Surgical treatment of abdominal aortic aneurysms by resection of the aneurysm and graft replacement is now an accepted procedure, but this has led to various postoperative complications. One example of this is secondary aortoenteric fistula. The diagnosis of aortoenteric fistula is often difficult to establish. We report a case of aortoenteric fistula that occurred 1 year after resection of the aneurysm and graft replacement. A 69‐year‐old man was admitted to our hospital following a sudden episode of melena. He had undergone aorto‐bifemoral bypass surgery with a prosthetic graft 1 year previously for abdominal aortic aneurysm. Upper gastrointestinal endoscopy and computed tomography scan were performed and aortoenteric fistula as a result of aortic anastomotic pseudoaneurysm, was diagnosed. In the first stage operation, an extra‐anatomic bypass was implanted from the right axillary artery to both femoral arteries. Removal of the graft and aortic stump closure were carried out in the second stage. The patient recovered uneventfully. This case shows the use of endoscopy for early diagnosis of secondary aortoenteric fistula.     

Aortoduodenal fistula as a cause of gastrointestinal bleeding--difficulties in endoscopic diagnosis

We report on three patients with severe gastrointestinal bleeding arising from aortoenteric fistula. Two patients presented with a secondary aortoduodenal fistula. In the first case bleeding occurred 8 months after aortobifemoral graft implantation. In the second patient aortobiliacal graft implantation was performed 22 years before. In the third case the aortoenteric fistula was primary and was caused by an abdominal aortic aneurysm without prior vascular intervention. In the first case diagnosis was made by urgent endoscopy visualizing ongoing bleeding from the duodenal fistula. In the two other patients urgent endoscopy and CT as well could not demonstrate the bleeding source. Aortoenteric fistula was diagnosed endoscopically during severe rebleeding some hours later. Two patients underwent surgery with implantation of an axillobifemoral bypass; the third patient declined further intervention and died. The course shows that aortoduodenal fistula can present with severe but intermittent gastrointestinal bleeding making the diagnosis in the non-bleeding interval difficult. In patients with severe gastrointestinal bleeding and a history of aortic disease (aneurysm, prior aortic graft repair or stenting) an aortoduodenal fistula should be suspected and the indication for surgical intervention should be considered early in spite of negative results of endoscopy and CT.     

Aorto-duodenal fistula--a rare cause of upper gastrointestinal hemorrhage]

Upper gastrointestinal hemorrhage is the most frequent indication for emergency endoscopy. In most of the cases the bleeding is primarily treated endoscopically. The duodenal penetration of an aortic graft implant is a rare condition, only accidentally diagnosed by endoscopy. This condition represents a difficult situation for the endoscopist since it is usually not included in the differential diagnosis. Additionally hemostasis can not be achieved by endoscopic intervention. Therefore the instant realization of this dangerous diagnosis is extremely important, because only surgical therapy in a center of vascular surgery may save the live of the patient.     

Photodiagnostic techniques for the endoscopic detection of premalignant gastrointestinal lesions

Considerable attention is given to the clinical diagnosis of gastrointestinal (GI) malignancies as they remain the second leading cause of cancer‐associated deaths in developed countries. Detection and intervention at an early stage of preneoplastic development significantly improve patient survival. High‐risk assessment of asymptomatic patients is currently performed by strict endoscopic surveillance biopsy protocols aimed at early detection of dysplasia and malignancy. However, poor sensitivity associated with frequent surveillance programs incorporating conventional screening tools, such as white light endoscopy and multiple random biopsy, is a significant limitation. Recent advances in biomedical optics are illuminating new ways to detect premalignant lesions of the GI tract with endoscopy. The present review presents a summary report on the newest developments in modern GI endoscopy, which are based on novel optical endoscopic techniques: fluorescence endoscopic imaging and spectroscopy, Raman spectroscopy, light scattering spectroscopy, optical coherence tomography, chromoendoscopy, confocal fluorescence endoscopy and immunofluorescence endoscopy. Relying on the interaction of light with tissue, these ‘state‐of‐the‐art’ techniques potentially offer an improved strategy for diagnosis of early mucosal lesions by facilitating targeted excisional biopsies. Furthermore, the prospects of real‐time ‘optical biopsy’ and improved staging of lesions may significantly enhance the endoscopist's ability to detect subtle preneoplastic mucosal changes and lead to curative endoscopic ablation of these lesions. Such advancements within this specialty will be rewarded in the long term with improved patient survival and quality of life.     

Percutaneous transhepatic sclerotherapy for recurrent bleeding ileal varices diagnosed by capsule endoscopy and computed tomography during percutaneous transhepatic venography

We report a case of acute uncontrolled gastrointestinal bleeding in a patient with liver cirrhosis. A 64‐year‐old man was admitted to our hospital for further investigation of blood in stools. Preliminary examination by computed tomography (CT) as well as upper and lower endoscopy could not detect the bleeding source. Exploratory laparotomy was considered difficult due to potential easy bleeding and adhesions caused by past abdominal surgery. The hemoglobin level was normalized by blood transfusion. Capsule endoscopy (CE) identified ileal varices. The top of these ileal varices was red, prompting their identification as the source of bleeding. Percutaneous transhepatic venography (PTV) confirmed the presence of many varices in the branch of the superior mesenteric vein, although the bleeding source could not be identified. CT during PTV identified varices protruding into the ileal lumen, which were managed subsequently by percutaneous transhepatic sclerotherapy (PTS). The procedure stopped the bleeding completely. CE proved less invasive and effective in detecting obscure gastrointestinal bleeding. CT during PTV followed by PTS is suitable for diagnosis and treatment of bleeding varices in patients with portal hypertension.     

Primary aortoduodenal fistula--report of an autopsy case

This report describes a case of primary aortoduodenal fistula (PADF) in an 83 year-old male admitted a local hospital with massive hematemesis. Endoscopy failed to reveal the site of hemorrhage. During his course, he had two episodes of hematemesis and melena. On the 77th hospital day, he died of acute hemorrhagic shock resulting from massive hemorrhage in the gastrointestinal tract. An autopsy revealed adhesion and a fistulous communication between an atherosclerotic abdominal aneurysm and the third portion of the duodenum. Primary aortoenteric fistula (PAEF), including PADF, is an uncommon but lethal complication of aortic aneurysm. Since fistula formation occurs most frequently between the abdominal aorta and duodenum, upper gastrointestinal endoscopic examination and aortography at the earliest possible moment are necessary to obtain a correct diagnosis before surgery.     

Advanced endoscopic imaging for diagnosis of inflammatory bowel diseases: Present and future perspectives

Crohn's disease and ulcerative colitis are chronic inflammatory bowel diseases (IBD) causing severe damage of the luminal gastrointestinal tract. Differential diagnosis between both disease entities is sometimes awkward requiring a multifactorial pathway, including clinical and laboratory data, radiological findings, histopathology and endoscopy. Apart from disease diagnosis, endoscopy in IBD plays a major role in prediction of disease severity and extent (i.e. mucosal healing) for tailored patient management and for screening of colitis‐associated cancer and its precursor lesions. In this state‐of‐the‐art review, we focus on current applications of endoscopy for diagnosis and surveillance of IBD. Moreover, we will discuss the latest guidelines on surveillance and provide an overview of the most recent developments in the field of endoscopic imaging and IBD.     

USEFULNESS OF MAGNIFYING ENDOSCOPY IN UPPER GASTROINTESTINAL TRACT: HISTORY AND RECENT STUDIES

Although clinical trials using magnifying optical endoscopy have been reported, magnifying endoscopies have been remarkably developed in the period of electronic endoscopy. Magnifying electronic endoscopies with 80 or 100‐fold magnification are used for routine endoscopic examination of upper gastrointestinal tract in Japan. Magnifying endoscopy is used to visualize the microstructure and microvascular architecture of gastrointestinal surface mucosa. Microsurface structure of the mucosa includes normal structure, changed structure by inflammation and biological response, and tumor‐specific structure. Microvascular architecture includes normal vascular system and tumor microvessels. Magnifying endoscopy is starting to play an important role in diagnosis of any upper gastrointestinal diseases by assessment of magnified observation. Magnifying endoscopy holds a great deal of promise in the near future because magnifying endoscopic observation is approaching optical biopsy.     

A typical presentation of a rare cause of obscure gastrointestinal bleeding

A 52-year-old white woman had suffered from intermittent gastrointestinal (GI) bleeding for one year. Upper GI endoscopy, colonoscopy and peroral doubleballoon enteroscopy (DBE) did not detect any bleeding sour ce, suggesting obscure GI bleeding. However, in video capsule endoscopy a jejunal ulceration without blee ding signs was suspected and this was endoscopically conf irmed by another peroral DBE. After transfusion of packed red blood cells, the patient was discharged from our hospital in good general condition.Two weeks later she was readmitted because of another episode of acute bleeding. Multi-detector row computed tomography with 3D reconstruction was performed revealing a jejunal tumor causing lower gastrointestinal bleeding. The patient underwent exploratory laparotomy with partial jejunal resection and end-to-end jejunostomy for reconstruction. Histological examination of the specimen confirmed the diagnosis of a low risk gastrointestinal stromal tumor (GIST). Nine days after surgery the patient was discharged in good health. No signs of gastrointestinal rebleeding occurred in a followup of eight months. We herein describe the comp lex presentation and course of this patient with GIST and also review the current approach to treatm ent.     

Diaphragm disease after use of nonsteroidal anti-inflammatory agents: first report of diagnosis with capsule endoscopy

Diaphragm disease of the small intestine is part of the spectrum of diseases associated with injury to the gastrointestinal tract induced by nonsteroidal anti-inflammatory drugs. Standard endoscopy or contrast studies of the small intestine rarely identify these lesions. The diagnosis usually is established at the time of surgery. We report the case of a 72-year-old woman with obscure gastrointestinal bleeding and intermittent obstruction of the small intestine who had had multiple hospitalizations and extensive testing. The patient had been treated with nonsteroidal anti-inflammatory drugs for osteoarthritis. A radiograph of the small intestine with barium contrast revealed no abnormalities, so capsule endoscopy was performed. Capsule endoscopy showed multiple small intestinal strictures beyond which the capsule could not pass. After the patient experienced continued symptoms suggestive of intermittent partial obstruction of the small intestine, computed tomography showed the capsule within a dilated loop of intestine adjacent to a stricture. After 9 days of conservative medical therapy and worsening symptoms, the patient required an exploratory laparotomy. The capsule was located in a 12-cm segment of intestine with 4 diaphragm-like lesions. Pathologic study found submucosal lesions with features identical to those of neuromuscular and vascular hamartoma (eg, mature, reactive tissue elements of smooth muscle, dense fibrous tissue, and nerve tissue bundles with scattered ganglion cells and vessels). No manifestations of Crohn disease were evident. This case represents the first diagnosis with capsule endoscopy of diaphragm disease of the small intestine with pathologic features of neuromuscular and vascular hamartoma.     

Obscure gastrointestinal bleeding: Diagnosis and treatment

Small‐bowel bleeding comprises a majority of obscure gastrointestinal bleeding, but is caused by various kinds of diseases. For its diagnosis, history‐taking and physical examination is requisite, leading to a suspicion of what diseases are involved. Next, cross‐sectional imaging such as computed tomography should be done, followed by the latest enteroscopy, videocapsule endoscopy and deep enteroscopy according to the severity of hemorrhage and patient conditions. After comprehensive diagnosis, medical, enteroscopic, or surgical treatment should be selected.     

Une observation rare d’occlusion intestinale : double invagination intestinale sur sonde de jéjunostomie

The intussusception secondary to an unusual cause is a rare abdominal emergency posposing a diagnostic and therapeutic problem.We report a patient aged 23 who ingested two sips of spirit of salt as part of a suicide attempt. An upper gastrointestinal endoscopy showed a stage IIb esophageal and gastric lesion. A month later the patient presented with dysphagia for solids for which he received a feeding jejunostomy. The evolution was marked by the installation of a double intussusception of jejunostomy tube requiring surgery with no complications. Improving the management and prognosis of IIA secondary to an unusual cause requires an early diagnosis. The reduction of this particular form of intussusception is almost exclusively surgical.     

Surgical management of gastrointestinal bleeding

Severe gastrointestinal bleeding has historically been a clinical problem primarily under the purview of the general surgeon. Diagnostic advances made as the result of newer technologies, such as fiberoptic and video endoscopy, selective visceral arteriography, and nuclear scintigraphy, have permitted more accurate and targeted operations. More importantly, they have led to safe, effective nonoperative therapeutic interventions that have obviated the need for surgery in many patients. Today, most gastrointestinal bleeding episodes are initially managed by endoscopic or angiographic control measures. Such interventions are often definitive in obtaining hemostasis. Even temporary cessation or attenuation of massive bleeding in an unstable patient permits a safer, more controlled operative procedure by allowing an adequate period of preoperative resuscitation. Despite the less frequent need for surgical intervention, traditional operative approaches, such as suture ligation, lesion or organ excision, vagotomy, portasystemic anastomosis, and devascularization procedures, continue to be life-saving in many instances. The proliferation of laparoscopic surgery has fostered the application of minimally invasive techniques to highly selected patients with gastrointestinal bleeding. Intraoperative endoscopy has greatly facilitated the accuracy of laparoscopic surgery by endoscopic localization of bleeding lesions requiring excision. It is anticipated that the evolving technologies pertinent to the diagnosis and management of gastrointestinal bleeding will continue to promote collaboration and cooperation between gastroenterologists, radiologists, and surgeons.     

Case Report: Gastrointestinal tuberculosis simulating Crohn's disease

A male Caucasian presented with abdominal pain and a right iliac fossa mass. There were no risk factors for Mycobacterium tuberculosis infection. He was investigated by upper and lower gastrointestinal endoscopy, chest and small bowel radiology. The latter showed stricturing of the third and fourth parts of the duodenum, mid-jejunum and terminal ileum. Biopsies were non-specific and he was thought to have Crohn's disease. Subsequent treatment with corticosteroids resulted in improved well being and weight gain; however, the patient demonstrated disease progression with the development of complex fistulae and Escherichia coli septicaemia. At surgery the patient was found to have an ileal inflammatory mass with fistulae to the sigmoid colon. The terminal ileum, fistulae and a segment of colon were resected. Treatment with anti-tuberculous drugs ensued and the patient is now asymptomatic after 15 months of follow-up. This case serves to highlight the difficulty in making the diagnosis of gastrointestinal tuberculosis, a disease that may mimic Crohn's disease, and the need for caution in the use of corticosteroids in any disease in which tuberculosis enters into the differential diagnosis. The role of surgery in making the diagnosis and managing the complications, in conjunction with anti-tuberculous drugs, and the prospect of cure are exemplified by this case.     

Comparison of emergent endoscopy and upper gastrointestinal series radiography in acute upper gastrointestinal haemorrhage.

A prospective study of early diagnostic procedures in acute upper gastrointestinal haemorrhage was conducted in a series of 76 patients. The diagnostic procedures included upper gastrointestinal series radiography (UGIS) and endoscopy (ENDO). The clinicians' diagnosis and management improved in a statistically significant way as a result of the findings of endoscopy. The findings of UGIS did not significantly improve diagnostic accuracy and resulted in a statistically significant adverse effect on patient management. The results suggest that endoscopy is more effective in promoting early accurate diagnosis and management in patients with acute upper gastrointestinal haemorrhage.     

Clinical features and endoscopic management of Dieulafoy's disease.

The experience of a specialized management team using urgent endoscopy in the management of acute gastrointestinal bleeding from Dieulafoy's disease is presented. Dieulafoy's disease was found in 19 of 1124 consecutive patients with upper gastrointestinal bleeding. Most patients with Dieulafoy's disease were elderly men with severe acute upper gastrointestinal hemorrhage. Endoscopic diagnosis was possible in all patients, but required multiple endoscopies in 37%. The lesions were in the proximal stomach (79%) and duodenal bulb (21%). Endoscopic therapy included epinephrine injection, then heater probe coagulation in 17 patients, bipolar electrocoagulation in 1, and Nd:YAG laser photocoagulation in 1. Endoscopic therapy was successful in 18 patients (95%); one patient had successful surgery after endoscopic therapy failed. There were no deaths due to bleeding and no endoscopic complications. Dieulafoy's disease is an unusual cause of acute gastrointestinal bleeding. Endoscopic diagnosis is sometimes difficult, but primary endoscopic therapy is safe, successful, and should be attempted.     

上消化道异物内镜急诊处理162例

目的:探讨上消化道异物内镜下急诊诊断及取出的处理方式.方法:2002-07/2011-07龙岗区第二人民医院胃镜室共完成内镜下急诊异物取出上消化道异物患者162例,男89例,女73例,年龄0.8-82岁,异物吞入后就诊时间为3min-9d,分析患者临床资料.结果:采用局麻或全麻下急诊用内镜直视下明确诊断,按照异物的位置、形态、大小、选择合适的器械,取出异物或设法让异物通过肠道排出体外.162例患者中155例通过上述方法治疗后取得满意疗效,7例患者治疗失败后改为手术处理,内镜下急诊取出治疗上消化道异物成功率为95.7%,部分并发咽喉黏膜损伤.结论:经内镜局麻或全麻下急诊取出上消化道异物是一种安全、有效的方法;手法得当,用内镜上消化道异物急诊取出应为首选方法,有器质性病变的患者取出异物后应尽早病因治疗.     

The use of endoscopy after gastric partitioning for morbid obesity

Fiberoptic endoscopy is an important diagnostic modality for evaluating the patient with upper gastrointestinal tract symptoms following gastric restrictive operations. The specific indications for endoscopy after obesity surgery include stoma evaluation in patients who fail to lose adequate weight; stomal stenosis; esophagitis; surveillance of the excluded pouch; and suspicion of a marginal ulcer after gastric bypass.