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Aortoenteric fistulas. Recognizing a potentially catastrophic cause of gastrointestinal bleeding
1Department of internal medicine, Vanderbilt University School of Medicine, Nashville, Tennessee.
Insights
Aortoenteric fistulas, a rare complication of aortic surgery, cause severe gastrointestinal bleeding. Prompt surgical intervention is critical for survival, as untreated cases have a near 100% mortality rate.
Area of Science:
- Vascular Surgery
- Gastroenterology
- Diagnostic Imaging
Background:
- Aortoenteric fistulas are rare but life-threatening complications following aortic reconstructive surgery.
- They commonly involve the proximal aortic graft anastomosis and the distal duodenum.
Observation:
- Patients often present with initial bleeding followed by catastrophic hemorrhage.
- A high index of suspicion is crucial for patients with a history of aortic surgery and gastrointestinal bleeding.
- Diagnostic imaging may be inconclusive, necessitating further investigation.
Findings:
- Massive gastrointestinal hemorrhage is the hallmark of aortoenteric fistulas.
- Exploratory laparotomy is indicated for patients with severe bleeding or negative diagnostic studies.
- Complete graft excision is the preferred surgical treatment.
Implications:
- Early surgical intervention is paramount to reduce the near 100% mortality rate associated with untreated aortoenteric fistulas.
- This condition underscores the importance of vigilant monitoring post-aortic reconstructive procedures.
- Timely diagnosis and aggressive management are essential for patient survival.
Abstract:
Aortoenteric fistulas are a relatively rare but serious cause of massive gastrointestinal hemorrhage. Most occur as a consequence of aortic reconstructive surgery and involve the proximal graft anastomosis. The distal duodenum is the site of bleeding in about three fourths of cases. Most patients have an initial episode of bleeding followed hours to weeks later by catastrophic hemorrhage. Patients with gastrointestinal bleeding who have undergone prior aortic reconstructive surgery should be approached with a great sense of urgency and a high index of suspicion. Endoscopic and radiographic studies can be very helpful, but the absence of abnormalities does not exclude the diagnosis. Exploratory laparotomy is indicated in patients with massive bleeding or those in whom results of other diagnostic studies have been normal. Treatment of aortoenteric fistula is early surgical intervention. Complete excision of the graft is preferred over patching or closing the defect. The mortality rate is essentially 100% without prompt surgical treatment.