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Published on: July 11, 2013
Diagnosis and management of primary aortoenteric fistulas--experience learned from eighteen patients
Yang Song1, Quanda Liu, Hong Shen
1Emergency Department, Chinese PLA General Hospital, Beijing, China.
Insights
Primary aortoenteric fistula (PAEF) is rare and often misdiagnosed. Prompt diagnosis and management, potentially with in situ graft replacement or endovascular stent-grafts, are crucial for patient survival.
Area of Science:
- Vascular Surgery
- Gastroenterology
- Diagnostic Imaging
Background:
- Primary aortoenteric fistula (PAEF) is a rare condition often presenting with vague symptoms, leading to frequent misdiagnosis.
- The rarity and diverse presentations of PAEF pose significant diagnostic challenges in clinical practice.
Purpose of the Study:
- To review the diagnostic and management experiences of PAEF at two medical centers.
- To highlight the importance of a high index of suspicion for timely diagnosis and treatment of PAEF.
Main Methods:
- Retrospective review of 18 patients diagnosed with PAEF.
- Evaluation of clinical data, diagnostic procedures, treatment strategies, and patient outcomes.
Main Results:
- Fistulas involved the esophagus, duodenum, jejunum, ileum, and colon, with etiologies including atherosclerotic aneurysms and foreign bodies.
- The typical abdominal triad was present in only 27.8% of patients; misdiagnosis occurred in 15 patients (mean 1.8 rounds).
- Surgical options included in situ graft replacement and endovascular stent-graft, with 6 patients recovering and remaining well at 36-month follow-up.
Conclusions:
- A high index of suspicion is essential for diagnosing PAEF, particularly in patients with aortoiliac aneurysms and gastrointestinal bleeding.
- In situ graft replacement and endovascular stent-graft are effective therapeutic options for PAEF.
Objective:
Misdiagnosis of primary aortoenteric fistula (PAEF) frequently occurs in clinical practice owing to the rarity of this condition. Herein we present the experience of diagnosis and management for PAEF.
Methods:
Eighteen patients with PAEF at 2 medical centers in China were reviewed. The clinical data, diagnostic procedures, treatment options, and patient outcomes were evaluated.
Results:
The fistulas were located at esophagus (5), duodenum (8), jejunum (3), ileum (1), and transverse colon (1). The etiologies include atherosclerotic aneurysms and foreign body. Typical abdominal triad (pain, upper GI bleeding, and abdominal pulsating mass) was found in 27.8% of patients, and Chiari's triad (mid-thoracic pain, sentinel hemorrhage, and massive bleeding after a symptom-free interval) was present in 3 of 5 cases with thoracic aortoesophageal fistulas. All patients had an average of 3.6 (1-9) episodes of gastrointestinal bleeding. The interval between the first sentinel hemorrhage and ultimate exsanguination ranged from 5 hours to 5 months (median, 4 days). Six patients (33.3%) were diagnosed or suggested by diagnostic tools including endoscopy, computerized tomography, and arteriography. Others were diagnosed by surgical exploration (7) and autopsy (5). One to 5 rounds (mean 1.8) of misdiagnosis occurred in 15 patients. Six patients recovered from surgery and remained well during a 36-month follow-up. The surgical options used included in situ replacement with vascular graft (3), aneurysmorraphy and closure of fistula (1), and endovascular stenting (2).
Conclusions:
A high index of suspicion is necessary for correct diagnosis and prompt management of PAEF, especially in patients with aortoiliac aneurysms presenting with gastrointestinal bleeding. In situ graft replacement and endovascular stent-graft may be the preferred therapeutic options.
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