Aortoenteric fisulta: Difference between revisions
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==Background== | ==Background== | ||
*Fistula formed between aorta and intestines | |||
* Can form fistula anytime within life of AAA graft repair | **Can be primary or secondary (often due to [[AAA]] repair) | ||
< | **Can form fistula anytime within life of [[AAA]] graft repair | ||
***Higher risk with recent graft placement | |||
*Involves the duodenum (ADF) in most cases<ref>Rodrigues dos Santos et al. Enteric repair in aortoduodenal fistulas: a forgotten but often lethal player. Ann Vasc Surg. 2014 Apr;28(3):756-62. doi: 10.1016/j.avsg.2013.09.004. Epub 2013 Oct 1.</ref> | |||
*Incidence of primary aortoenteric fistulas is estimated to be about 0.007 per million while secondary aortoenteric fistulas is about 0.6-2% | |||
*Mortality of 100% if left untreated | |||
==Clinical Features== | ==Clinical Features== | ||
* Classic triad | *Classic triad: [[abdominal pain]], [[GI bleeding]] and pulsatile abdominal mass | ||
*Low grade fever | **Present in 23% of patients | ||
* | *Low grade [[fever]] | ||
*Back pain | *[[Abdominal pain]] | ||
* | *[[Back pain]] | ||
*BRBPR | *History of [[AAA]] graft | ||
*[[BRBPR]] or [[melena]] | |||
**Herald bleed - initial melena or hematochezia with few hemodynamic changes; then followed by severe bleed | |||
==Differential Diagnosis== | ==Differential Diagnosis== | ||
{{UGIB DDX}} | |||
{{Lower GI bleeding DDX}} | {{Lower GI bleeding DDX}} | ||
== | ==Evaluation== | ||
* CBC | [[File:AortoEntericFistulaDissectionMark.png|thumb|Aortoenteric fistula and aortic dissection of the thoracic aorta. Arrow shows the flap in the aorta. Heterogeneity is blood in the stomach.]] | ||
* Chem 10 | [[File:PMC4393498 Iranjradiol-12-02-22759-g001.png|thumb|Aortoenteric fistula on CT showing extensive atherosclerosis of abdominal aorta and an infrarenal thrombosed aneurysm. In the extension of the thrombosed aneurysm, a soft tissue density is extending anteriorly (arrow), adherent to the duodenum and slightly compressing it.]] | ||
* Type and Cross | '''If suspicion high, involve vascular surgery early''' | ||
* PT/INR/PTT | *CBC | ||
* | *Chem 10 | ||
* | *Type and Cross | ||
* CTA of abdomen/pelvis, highly sensitive, if patient stable | *PT/INR/PTT | ||
* Patient may need gastroduodenal endoscopy | *Blood culture if fever - high risk for infections with secondary fistulas (ie grafts) | ||
*[[Aortic ultrasound]] and [[FAST exam]] to assess for AAA and Free Fluid | |||
*[[CXR]] for pre-op, if patient stable | |||
*[[ECG]] for pre-op | |||
*CTA of abdomen/pelvis, highly sensitive, if patient stable | |||
*Patient may need gastroduodenal endoscopy | |||
==Management== | ==Management== | ||
*[[Fluid resuscitation]] | |||
*Transfuse [[pRBCs]] as needed | |||
*Surgical Intervention | |||
**Transfer if not available | |||
==Disposition== | ==Disposition== | ||
*Admission | |||
==External Links== | ==External Links== | ||
== | ==References== | ||
<references/> | <references/> | ||
[[Category:GI]] | [[Category:GI]] | ||
[[Category:Vascular]] | |||
[[category:Surgery]] | |||
Latest revision as of 21:48, 8 July 2021
Background
- Fistula formed between aorta and intestines
- Involves the duodenum (ADF) in most cases[1]
- Incidence of primary aortoenteric fistulas is estimated to be about 0.007 per million while secondary aortoenteric fistulas is about 0.6-2%
- Mortality of 100% if left untreated
Clinical Features
- Classic triad: abdominal pain, GI bleeding and pulsatile abdominal mass
- Present in 23% of patients
- Low grade fever
- Abdominal pain
- Back pain
- History of AAA graft
- BRBPR or melena
- Herald bleed - initial melena or hematochezia with few hemodynamic changes; then followed by severe bleed
Differential Diagnosis
Upper gastrointestinal bleeding
- Peptic ulcer disease (most common cause)
- Gastritis/esophagitis
- Gastric/esophageal varices
- Mallory-Weiss tear
- Malignancy
- Aortoenteric fisulta
- Boerhaave
- Dieulafoy's lesion
- Angiodysplasia
- Hemobilia
- Hemorrhagic gastritis, EtOH
- Celiac disease
- Dengue
- Other intrabdominal bleeds
- Lower GI bleeding
- Hemorrhagic pancreatitis
- Splenic rupture
- Subcapsular cavernous hemangiomas
- Peliosis hepatis
Mimics of GI Bleeding
- Hemoptysis
- Vaginal/Urethra bleeding
- ENT bleeding
- Dietary (Iron, bismuth, beets)
- Swallowed maternal blood (in neonate)
Undifferentiated lower gastrointestinal bleeding
- Upper GI Bleeding
- Diverticular disease
- Vascular ectasia / angiodysplasia
- Inflammatory bowel disease
- Infectious colitis
- Mesenteric Ischemia / ischemic colitis
- Meckel's diverticulum
- Colorectal cancer / polyps
- Hemorrhoids
- Aortoenteric fistula
- Nearly 100% mortality if untreated
- Consider in patients with gastrointestinal bleeding and known abdominal aortic aneurysms or aortic grafts
- Rectal foreign body
- Rectal ulcer (HIV, Syphilis, STI)
- Anal fissure
Evaluation
If suspicion high, involve vascular surgery early
- CBC
- Chem 10
- Type and Cross
- PT/INR/PTT
- Blood culture if fever - high risk for infections with secondary fistulas (ie grafts)
- Aortic ultrasound and FAST exam to assess for AAA and Free Fluid
- CXR for pre-op, if patient stable
- ECG for pre-op
- CTA of abdomen/pelvis, highly sensitive, if patient stable
- Patient may need gastroduodenal endoscopy
Management
- Fluid resuscitation
- Transfuse pRBCs as needed
- Surgical Intervention
- Transfer if not available
Disposition
- Admission
External Links
References
- ↑ Rodrigues dos Santos et al. Enteric repair in aortoduodenal fistulas: a forgotten but often lethal player. Ann Vasc Surg. 2014 Apr;28(3):756-62. doi: 10.1016/j.avsg.2013.09.004. Epub 2013 Oct 1.