Difference between revisions of "Aortoenteric fisulta"

(Evaluation)
 
(14 intermediate revisions by 5 users not shown)
Line 1: Line 1:
 
==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
 
*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>
 
*Incidence of primary aortoenteric fistulas is estimated to be about 0.007 per million while secondary aortoenteric fistulas is about 0.6-2%
 
*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 of abdominal pain, GI bleeding and pulsatile abdominal mass only present in 23% of patients
+
*Classic triad: [[abdominal pain]], [[GI bleeding]] and pulsatile abdominal mass  
*Low grade fever
+
**Present in 23% of patients
*abd pain
+
*Low grade [[fever]]
*Back pain
+
*[[Abdominal pain]]
*H/o AAA graft
+
*[[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}}
  
==Workup==
+
==Evaluation==
'''* If suspicion high, involve vascular surgery early'''
+
[[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
 
*CBC
 
*Chem 10
 
*Chem 10
Line 24: Line 31:
 
*PT/INR/PTT
 
*PT/INR/PTT
 
*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)
*CXR for pre-op, if patient stable
+
*[[Aortic ultrasound]] and [[FAST exam]] to assess for AAA and Free Fluid
*EKG for pre-op
+
*[[CXR]] for pre-op, if patient stable
 +
*[[ECG]] 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
  
 
==Management==
 
==Management==
 +
*[[Fluid resuscitation]]
 +
*Transfuse [[pRBCs]] as needed
 
*Surgical Intervention
 
*Surgical Intervention
 
**Transfer if not available
 
**Transfer if not available
Line 38: Line 48:
 
==External Links==
 
==External Links==
  
==Sources==
+
==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
    • 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[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

Differential Diagnosis

Upper gastrointestinal bleeding

Mimics of GI Bleeding

Lower gastrointestinal bleeding

Evaluation

Aortoenteric fistula and aortic dissection of the thoracic aorta. Arrow shows the flap in the aorta. Heterogeneity is blood in the stomach.
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

Disposition

  • Admission

External Links

References

  1. 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.