Difference between revisions of "Aortoenteric fisulta"
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==Background== | ==Background== | ||
| + | *Fistula formed between aorta and intestines | ||
| + | **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== | ||
| − | *Low grade fever | + | *Classic triad: [[abdominal pain]], [[GI bleeding]] and pulsatile abdominal mass |
| − | * | + | **Present in 23% of patients |
| − | *Back pain | + | *Low grade [[fever]] |
| − | * | + | *[[Abdominal pain]] |
| − | *BRBPR | + | *[[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== | ==Differential Diagnosis== | ||
| + | {{UGIB DDX}} | ||
{{Lower GI bleeding DDX}} | {{Lower GI bleeding DDX}} | ||
| − | == | + | ==Evaluation== |
| + | [[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.]] | ||
| + | [[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.]] | ||
| + | '''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== | ==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:Vascular]] | ||
| + | [[category:Surgery]] | ||
Latest revision as of 21:48, 8 July 2021
Contents
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
- 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)
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.