Difference between revisions of "Aortoenteric fisulta"

(Text replacement - "Ultrasound: Aorta" to "Aortic ultrasound")
(Evaluation)
 
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*Low grade [[fever]]
 
*Low grade [[fever]]
 
*[[Abdominal pain]]
 
*[[Abdominal pain]]
*Back pain
+
*[[Back pain]]
 
*History of [[AAA]] graft
 
*History of [[AAA]] graft
 
*[[BRBPR]] or [[melena]]
 
*[[BRBPR]] or [[melena]]
*Herald bleed - initial melena or hematochezia with few hemodynamic changes; then followed by severe bleed
+
**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}}
  
==Diagnosis==
+
==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'''
 
'''If suspicion high, involve vascular surgery early'''
 
*CBC
 
*CBC
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*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)
*[[Aortic ultrasound]] and [[Ultrasound: FAST]] to assess for AAA and Free Fluid
+
*[[Aortic ultrasound]] and [[FAST exam]] to assess for AAA and Free Fluid
 
*[[CXR]] for pre-op, if patient stable
 
*[[CXR]] for pre-op, if patient stable
 
*[[ECG]] for pre-op
 
*[[ECG]] for pre-op
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==Management==
 
==Management==
*Fluid resuscitation
+
*[[Fluid resuscitation]]
 
*Transfuse [[pRBCs]] as needed
 
*Transfuse [[pRBCs]] as needed
 
*Surgical Intervention
 
*Surgical Intervention
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[[Category:GI]]
 
[[Category:GI]]
 
[[Category:Vascular]]
 
[[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.