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Primary aortoenteric fistula
The American Journal of Surgery 195 (2008) 506 –507
Clinical image
Primary aortoenteric fistula Graham Roche-Nagle, M.D.a,*, David H. O’Donnell, M.D.b, David P. Brophy, M.D.a, Mary C. Barry, M.D.b a
Department of Vascular and Endovascular Surgery, St. Vincent’s Hospital, Dublin 4, Ireland b Department of Radiology, St Vincent’s Hospital, Dublin, Ireland Manuscript received January 13, 2007; revised manuscript March 27, 2007
Abstract A 78-year-old woman presented with a gastrointestinal hemorrhage and palpable abdominal aortic aneurysm. The computed tomography scan of the abdomen showed a primary aortoenteric fistula. The challenging clinical diagnosis of aortoenteric fistulae and their surgical treatment options are discussed. © 2008 Elsevier Inc. All rights reserved. Keywords: Abdominal aortic aneurysm; Aortoenteric fistula; Computed tomography
A 78-year-old woman was admitted to our department with abdominal pain and a large gastrointestinal hemorrhage. Examination of her abdomen revealed a palpable abdominal aortic aneurysm, and the diagnosis of an aortoenteric fistula was considered. The diagnosis was confirmed by a computed tomography scan showing a primary aortoduodenal fistula with a 6-cm aortic aneurysm (Fig. 1). The patient was successfully operated on. During the urgent operation, we found the penetrating atherosclerotic ulcer as the cause of the aortoduodenal communication (Fig. 2). Because of the lack of gross infection at the site of the fistula, an in situ prosthesis was used. The management of patients with vascular-enteric fistulas remains a challenging diagnostic and therapeutic problem for the vascular surgeon. Aortoenteric fistulas (AEFs) are classified as primary [1] and secondary [2]. Primary AEFs commonly arise from atherosclerotic or inflammatory abdominal aneurysm, radiotherapy, and tuberculosis, whereas secondary AEFs usually follow previous arterial reconstructive surgery. Primary AEFs are rare clinical entites that result in fatal exsanguination if undiagnosed. They are in the majority of cases (90%) the result of erosion of the bowel wall, caused by abdominal aortic aneurysm [3], and mostly involve the third portion of the duodenum [4]. The diagnosis and management of such patients is especially difficult because they are so uncommon. For two thirds of the patients, the diagnosis is made in the operating room [5]. The classic trio of abdominal pain, palpable mass, and gastrointestinal bleeding only occurs in 11% of patients [6]. When the etiology is an aortic aneurysm, a palpable mass can be found in 25% to 70% of the patients [1,3]. The outcome will depend on the timeliness of diagnosis, the patient’s general state, the degree of contamination, and the * Corresponding author. Tel.: ⫹00353-1-221-4000; fax: ⫹00353-1-269-6018. E-mail address: [email protected] 0002-9610/08/$ – see front matter © 2008 Elsevier Inc. All rights reserved. doi:10.1016/j.amjsurg.2007.03.015
Fig. 1. (A) An unenhanced axial CT scan through the inferior aspect of the aortic aneurysm. The arrow shows abnormal soft-tissue density surrounding the anterolateral aneurysm. (B) An enhanced axial CT scan shows extensive thrombus within the vessel lumen. The third part of the duodenum is adherent to the calcified wall of the aneurysm. There is enhancement in the overlying fibrous tissue, which is another characteristic finding in inflammatory aneurysms. The arrow shows a small pocket of air seen in the thickened tissue, which is not continuous with the intraluminal air in the duodenum. This is suspicious in the setting of an inflammatory aneurysm for an aortoenteric fistula.
G. Roche-Nagle et al. / The American Journal of Surgery 195 (2008) 506 –507
507
anatomic site of the aorta involved. The conventional treatment of infrarenal aortic infection includes primary intestinal suture or resection and intestinal anastomosis, excision, and drainage of infection with the oversewing of the infrarenal aorta combined with axillofemoral bypass grafting [7]. The alternative of extra-anatomic grafting is used in situations in which the previously described procedure cannot be performed (ie, in infectious aneurysms of the aorta that involve the visceral branches) [8]. In these cases, the synthetic prosthesis is placed in situ. In the infrarenal aortic segment, in the absence of gross pus at the site of the fistula, in situ prosthesis grafting is increasingly being performed [9]. References
Fig. 2. (A) Inflammatory aneurysm with duodenum attached (arrow). (B) An opened sac revealing aortoenteric fistula into the third part of the duodenum (arrow).
[1] Sweeney MS, Gadacz TR. Primary aortoduodenal fistula: manifestation, diagnosis, and treatment. Surgery 1984;96:492–7. [2] Perler BA, Ernst CB. Infected aneurysms. In: Veith FJ, Hobson RW, Williams RA, Wilson SE, editors. Vascular Surgery: Principles and Practice. New York: McGraw-Hill; 1994:589 – 608. [3] Calligaro KD, Bergen WS, Savarese RP, et al. Primary aortoduodenal fistulae due to septic aortitis. J Cardiovasc Surg 1992;33:192– 8. [4] Lee JT, Saroyan RM, Belzberg G, et al. Primary aortoenteric fistula: computed tomographic diagnosis of an atypical presentation. Ann Vasc Surg 2001;15:251– 4. [5] Dossa CD, Pipinos I, Shepard AD, et al. Primary aortoenteric fistula. Ann Vasc Surg 1994;8:113–20. [6] Saers SJ, Scheltinga MR. Primary aortoenteric fistula. Br J Surg 2005; 92:143–52. [7] Yegar RA, Taylor LM Jr, Moneta GL, et al. Improved results with conventional management of infrarenal aortic infection. J Vasc Surg 1999;30:76 – 83. [8] Svensson LG, Crawford ES. Aortic infections. In: Svensson LG, Crawford ES, editors. Cardiovascular and Vascular Disease of the Aorta. Philadelphia: WB Saunders; 1997:126 –52. [9] Walker WE, Cooley DA, Duncan JM, et al. The management of aortoduodenal fistula by in situ replacement of the infected abdominal aortic graft. Ann Surg 1987;205:727–32.
Clinical image
Primary aortoenteric fistula Graham Roche-Nagle, M.D.a,*, David H. O’Donnell, M.D.b, David P. Brophy, M.D.a, Mary C. Barry, M.D.b a
Department of Vascular and Endovascular Surgery, St. Vincent’s Hospital, Dublin 4, Ireland b Department of Radiology, St Vincent’s Hospital, Dublin, Ireland Manuscript received January 13, 2007; revised manuscript March 27, 2007
Abstract A 78-year-old woman presented with a gastrointestinal hemorrhage and palpable abdominal aortic aneurysm. The computed tomography scan of the abdomen showed a primary aortoenteric fistula. The challenging clinical diagnosis of aortoenteric fistulae and their surgical treatment options are discussed. © 2008 Elsevier Inc. All rights reserved. Keywords: Abdominal aortic aneurysm; Aortoenteric fistula; Computed tomography
A 78-year-old woman was admitted to our department with abdominal pain and a large gastrointestinal hemorrhage. Examination of her abdomen revealed a palpable abdominal aortic aneurysm, and the diagnosis of an aortoenteric fistula was considered. The diagnosis was confirmed by a computed tomography scan showing a primary aortoduodenal fistula with a 6-cm aortic aneurysm (Fig. 1). The patient was successfully operated on. During the urgent operation, we found the penetrating atherosclerotic ulcer as the cause of the aortoduodenal communication (Fig. 2). Because of the lack of gross infection at the site of the fistula, an in situ prosthesis was used. The management of patients with vascular-enteric fistulas remains a challenging diagnostic and therapeutic problem for the vascular surgeon. Aortoenteric fistulas (AEFs) are classified as primary [1] and secondary [2]. Primary AEFs commonly arise from atherosclerotic or inflammatory abdominal aneurysm, radiotherapy, and tuberculosis, whereas secondary AEFs usually follow previous arterial reconstructive surgery. Primary AEFs are rare clinical entites that result in fatal exsanguination if undiagnosed. They are in the majority of cases (90%) the result of erosion of the bowel wall, caused by abdominal aortic aneurysm [3], and mostly involve the third portion of the duodenum [4]. The diagnosis and management of such patients is especially difficult because they are so uncommon. For two thirds of the patients, the diagnosis is made in the operating room [5]. The classic trio of abdominal pain, palpable mass, and gastrointestinal bleeding only occurs in 11% of patients [6]. When the etiology is an aortic aneurysm, a palpable mass can be found in 25% to 70% of the patients [1,3]. The outcome will depend on the timeliness of diagnosis, the patient’s general state, the degree of contamination, and the * Corresponding author. Tel.: ⫹00353-1-221-4000; fax: ⫹00353-1-269-6018. E-mail address: [email protected] 0002-9610/08/$ – see front matter © 2008 Elsevier Inc. All rights reserved. doi:10.1016/j.amjsurg.2007.03.015
Fig. 1. (A) An unenhanced axial CT scan through the inferior aspect of the aortic aneurysm. The arrow shows abnormal soft-tissue density surrounding the anterolateral aneurysm. (B) An enhanced axial CT scan shows extensive thrombus within the vessel lumen. The third part of the duodenum is adherent to the calcified wall of the aneurysm. There is enhancement in the overlying fibrous tissue, which is another characteristic finding in inflammatory aneurysms. The arrow shows a small pocket of air seen in the thickened tissue, which is not continuous with the intraluminal air in the duodenum. This is suspicious in the setting of an inflammatory aneurysm for an aortoenteric fistula.
G. Roche-Nagle et al. / The American Journal of Surgery 195 (2008) 506 –507
507
anatomic site of the aorta involved. The conventional treatment of infrarenal aortic infection includes primary intestinal suture or resection and intestinal anastomosis, excision, and drainage of infection with the oversewing of the infrarenal aorta combined with axillofemoral bypass grafting [7]. The alternative of extra-anatomic grafting is used in situations in which the previously described procedure cannot be performed (ie, in infectious aneurysms of the aorta that involve the visceral branches) [8]. In these cases, the synthetic prosthesis is placed in situ. In the infrarenal aortic segment, in the absence of gross pus at the site of the fistula, in situ prosthesis grafting is increasingly being performed [9]. References
Fig. 2. (A) Inflammatory aneurysm with duodenum attached (arrow). (B) An opened sac revealing aortoenteric fistula into the third part of the duodenum (arrow).
[1] Sweeney MS, Gadacz TR. Primary aortoduodenal fistula: manifestation, diagnosis, and treatment. Surgery 1984;96:492–7. [2] Perler BA, Ernst CB. Infected aneurysms. In: Veith FJ, Hobson RW, Williams RA, Wilson SE, editors. Vascular Surgery: Principles and Practice. New York: McGraw-Hill; 1994:589 – 608. [3] Calligaro KD, Bergen WS, Savarese RP, et al. Primary aortoduodenal fistulae due to septic aortitis. J Cardiovasc Surg 1992;33:192– 8. [4] Lee JT, Saroyan RM, Belzberg G, et al. Primary aortoenteric fistula: computed tomographic diagnosis of an atypical presentation. Ann Vasc Surg 2001;15:251– 4. [5] Dossa CD, Pipinos I, Shepard AD, et al. Primary aortoenteric fistula. Ann Vasc Surg 1994;8:113–20. [6] Saers SJ, Scheltinga MR. Primary aortoenteric fistula. Br J Surg 2005; 92:143–52. [7] Yegar RA, Taylor LM Jr, Moneta GL, et al. Improved results with conventional management of infrarenal aortic infection. J Vasc Surg 1999;30:76 – 83. [8] Svensson LG, Crawford ES. Aortic infections. In: Svensson LG, Crawford ES, editors. Cardiovascular and Vascular Disease of the Aorta. Philadelphia: WB Saunders; 1997:126 –52. [9] Walker WE, Cooley DA, Duncan JM, et al. The management of aortoduodenal fistula by in situ replacement of the infected abdominal aortic graft. Ann Surg 1987;205:727–32.