Gastrointestinal bleeding after aortic surgery: a case report
© Shitara and Wada; licensee BioMed Central Ltd. 2009
Received: 16 November 2009
Accepted: 23 November 2009
Published: 23 November 2009
An aortoenteric fistula is a communication between the aorta and an adjacent loop of the bowel. Here we report a case with this rare complication with typical herald bleeding.
A 66-year-old man underwent elective repair of a large supra-renal abdominal aortic aneurysm and returned 6 months later to our clinic after experiencing a melena with hematochezia. The source of bleeding could not be identified by gastroscopy but the following day he vomited a large volume of blood, rapidly became haemodynamically unstable and died of hypotensive shock. A CT scan on the same day showed an increasing area of low-density soft tissue around the graft wall compared with the previous CT scan images obtained initially after the aortic repair. An aortoenteric fistula was confirmed by autopsy.
In patients that underwent abdominal aortic surgery, both the occurrence of herald bleeding and CT findings of increasing para graft soft tissue might play a crucial role in early detection of aortoenteric fistula.
An aortoenteric fistula (AEF) is a communication between the aorta and an adjacent loop of the bowel. Primary fistulae occur without prior history of aortic intervention or repair and typically result from the erosion of an infected aorta into the posterior wall of the duodenum. Secondary fistulae develop after aortic intervention and typically involve a proximal suture line and/or prosthetic graft material. It is a rare complication following aortic graft surgery, with a reported incidence between 0.36-4% of patients who have undergone open aortic surgery[2, 3]. Here we report a case with this rare complication with typical herald bleeding.
An AEF is a communication between the aorta and an adjacent loop of bowel. The interval between aortic reconstructive surgery and the onset of gastrointestinal hemorrhage is varied. Most patients present with an initial episode of bleeding (herald bleed) followed by catastrophic hemorrhage as occurred in our case after a variable period of time. The difficulty in diagnosis of AEF was discussed in several literatures [1, 3, 4], and this is highlighted in our case. Although gastroduodenoscopy is important to exclude other source of bleeding, it has a low sensitivity to make the diagnosis of AEF. Abdominal CT scanning is reported to detect several abnormal findings in patients with AEF, such as increase of perigraft soft tissue, pseudoaneurysm formation, disruption of aneurismal wrap, and increased soft tissue between the graft and aneurismal wrap, although it has a low specificity for determining the presence of a fistula. So high suspicious should be maintained to consider the diagnosis of AEF. Curative treatment is only surgery because mortality reported 100% without surgery, although perioperative mortality also approximately 50%. For the diagnosis of the gastrointestinal bleeding in the patients following abdominal aortic surgery, especially in patients with intermittent bleeding and abnormal CT findings, AEF should be considered and early surgery should be prepared.
Conflict of interests
The authors declare that they have no competing interests.
Written informed consent was obtained from the patient' wife for publication of this case report and accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal.
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