Aortoenteric fisulta: Difference between revisions
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==Background== | ==Background== | ||
*Fistula formed between aorta and intestines | *Fistula formed between aorta and intestines | ||
**Can be primary or secondary (often due to AAA repair) | **Can be primary or secondary (often due to [[AAA]] repair) | ||
**Can form fistula anytime within life of AAA graft repair | **Can form fistula anytime within life of [[AAA]] graft repair | ||
***Higher risk with recent graft placement | ***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> | *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> | ||
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==Clinical Features== | ==Clinical Features== | ||
*Classic triad: abdominal pain, GI bleeding and pulsatile abdominal mass | *Classic triad: [[abdominal pain]], [[GI bleeding]] and pulsatile abdominal mass | ||
**Present in 23% of patients | **Present in 23% of patients | ||
*Low grade fever | *Low grade [[fever]] | ||
* | *[[Abdominal pain]] | ||
*Back pain | *Back pain | ||
* | *History of [[AAA]] graft | ||
*BRBPR or melena | *[[BRBPR]] or [[melena]] | ||
*Herald bleed - initial melena or hematochezia | *Herald bleed - initial melena or hematochezia with few hemodynamic changes; then followed by severe bleed | ||
==Differential Diagnosis== | ==Differential Diagnosis== | ||
{{Lower GI bleeding DDX}} | {{Lower GI bleeding DDX}} | ||
== | ==Diagnosis== | ||
'''*If suspicion high, involve vascular surgery early''' | '''*If suspicion high, involve vascular surgery early''' | ||
*CBC | *CBC | ||
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*Blood culture if fever - high risk for infections with secondary fistulas (ie grafts) | *Blood culture if fever - high risk for infections with secondary fistulas (ie grafts) | ||
*[[Ultrasound: Aorta]] and [[Ultrasound: FAST]] to assess for AAA and Free Fluid | *[[Ultrasound: Aorta]] and [[Ultrasound: FAST]] to assess for AAA and Free Fluid | ||
*CXR for pre-op, if patient stable | *[[CXR]] for pre-op, if patient stable | ||
*EKG for pre-op | *[[EKG]] for pre-op | ||
*CTA of abdomen/pelvis, highly sensitive, if patient stable | *CTA of abdomen/pelvis, highly sensitive, if patient stable | ||
*Patient may need gastroduodenal endoscopy | *Patient may need gastroduodenal endoscopy | ||
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==Management== | ==Management== | ||
*Fluid resuscitation | *Fluid resuscitation | ||
*Transfuse pRBCs as needed | *Transfuse [[pRBCs]] as needed | ||
*Surgical Intervention | *Surgical Intervention | ||
**Transfer if not available | **Transfer if not available | ||
Revision as of 15:50, 11 August 2015
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
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
Diagnosis
*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)
- Ultrasound: Aorta and Ultrasound: FAST to assess for AAA and Free Fluid
- CXR for pre-op, if patient stable
- EKG 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.